Introduction Intraductal papillary mucinous neoplasms (IPMNs) are common pancreatic cystic neoplasms with malignant potential. Current evidence on IPMN management is derived largely from retrospective surgical cohorts that over-represent high-risk cases and provide limited insight into the long-term outcomes of conservatively managed lesions. Australia currently lacks a prospective national dataset to evaluate surveillance pathways, practice patterns, guideline adherence and long-term outcomes in individuals with IPMN. Variation between international guideline recommendations may also contribute to differences in surveillance intensity and thresholds for intervention. The Australian Pancreatic Cyst Registry (APCR) was established to address these evidence gaps. Methods and analysis The APCR is a prospective, multicentre clinical quality registry that collects clinical, imaging, management and outcome data for individuals with IPMN across public and private healthcare settings in Australia. Historical information is extracted from existing clinical documentation where available, with prospective data collection continuing during routine follow-up. The registry operates under an opt-out model and aims to enrol up to 10 000 participants over a 5-year recruitment period. Participants are followed through routine clinical care until discharge from surveillance, diagnosis of pancreatic cancer, withdrawal or death. Standardised electronic case report forms capture clinical and imaging variables aligned with risk features described in the 2024 Kyoto guidelines. This analysis will describe participant characteristics, cyst features, management and clinical outcomes, with comparative, time-to-event and multivariable analyses undertaken where appropriate. Guideline adherence and the predictive performance of established risk stratification frameworks will also be evaluated. Ethics and dissemination The study protocol was approved by the Monash Health Human Research Ethics Committee (Project ID: RES-24-0000-634A). Findings will be disseminated through peer-reviewed publications, conference presentations and updates to participating sites.

ANZ Journal of SurgeryEarly View IMAGES FOR SURGEONS Cutaneous paraneoplastic presentation of underlying gallbladder malignancy Callum J. Prosser MBCHB, BMEDSCI, Callum J. Prosser MBCHB, BMEDSCI orcid.org/0000-0002-3393-4622 Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Writing - original draft, ConceptualizationSearch for more papers by this authorMatilda Anderson MBBS, MPH, Matilda Anderson MBBS, MPH Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Conceptualization, Writing - review & editingSearch for more papers by this authorSimon Banting MBBS, FRACS, Simon Banting MBBS, FRACS Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Supervision, Writing - review & editingSearch for more papers by this author Callum J. Prosser MBCHB, BMEDSCI, Callum J. Prosser MBCHB, BMEDSCI orcid.org/0000-0002-3393-4622 Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Writing - original draft, ConceptualizationSearch for more papers by this authorMatilda Anderson MBBS, MPH, Matilda Anderson MBBS, MPH Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Conceptualization, Writing - review & editingSearch for more papers by this authorSimon Banting MBBS, FRACS, Simon Banting MBBS, FRACS Hepatobiliary and Upper Gastrointestinal (GI) Surgery, Eastern Health, Boxhill Hospital, Melbourne, Victoria, Australia Contribution: Supervision, Writing - review & editingSearch for more papers by this author First published: 01 March 2024 https://doi.org/10.1111/ans.18910Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Hachulla E. Dermatomyosite et polymyosite: aspects cliniques et traitement [dermatomyositis and polymyositis: clinical aspects and treatment]. Ann. Med. Intern. (Paris). 2001; 152: 455–464. CASPubMedWeb of Science®Google Scholar 2Khanna U, Galimberti F, Li Y, Fernandez AP. Dermatomyositis and malignancy: should all patients with dermatomyositis undergo malignancy screening? Ann. Transl. Med. 2021; 99: 432. 10.21037/atm-20-5215 Google Scholar 3Paul A, Mukhopadhyay A, Ghosh SK, Samanta K, Das S. Paraneoplastic dermatomyositis in a case of gallbladder signet ring cell carcinoma. Cureus 2020; 12: e10730. PubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Toothpicks are commonly used but rarely ingested. Unlike most foreign bodies, if accidentally swallowed these rarely spontaneously pass. The duodenum has been reported as the most common site of toothpick foreign body lodgement in the upper gastrointestinal tract. We report the case of a 57-year-old presenting with recurrent urosepsis after non recognition of a toothpick impaction in the duodenum with fistulisation into the right renal pelvis. Endoscopic removal of the foreign body was successful in management of the urosepsis.

Background & AimsLiver sinusoidal endothelial cells (LSECs) are important in liver development, regeneration and pathophysiology, but the differentiation process underlying their tissue-specific phenotype is poorly understood and difficult to study as primary human cells are scarce. The aim of this study was to use human induced pluripotent stem cell (hiPSC)-derived LSEC-like cells to investigate the differentiation process of LSECs.MethodshiPSC-derived endothelial cells were transplanted into the livers of Fah−/−/Rag2−/−/Il2rg−/− mice and assessed over a 12-week period. Lineage tracing, immunofluorescence, flow cytometry, plasma human factor VIII measurement and bulk and single cell transcriptomic analysis were used to assess the molecular and functional changes that occur with transplantation.ResultsProgressive and long-term repopulation of the liver vasculature occurred as iECs expanded along the sinusoids between hepatocytes and increasingly produced human factor VIII, indicating differentiation into LSEC-like cells. To chart the developmental profile associated with LSEC specification, the bulk transcriptome of transplanted cells between 1- and 12-weeks post-transplantation were compared against primary human adult LSECs. This demonstrated a chronological increase in LSEC markers, LSEC differentiation pathways, and zonation. Bulk transcriptome analysis suggested that the transcription factors NOTCH1, GATA4, and FOS play a central role in LSEC specification, interacting with a network of 27 transcription factors. Novel markers associated with this process include EMCN and CLEC14A. Additionally, single cell transcriptomic analysis demonstrated that transplanted iECs at 4-weeks contain zonal subpopulations with a region-specific phenotype.ConclusionsCollectively, this study confirms that hiPSC can adopt LSEC-like features and provides insight into LSEC specification. This humanised xenograft system can be applied to further interrogate LSEC developmental biology and pathophysiology, bypassing current logistical obstacles associated with primary human LSECs.Impact And ImplicationsLiver sinusoidal endothelial cells (LSECs) are important cells for liver biology, but better model systems are required to study them. We present a pluripotent stem cell xenografting model which produces human LSEC-like cells. A detailed and longitudinal transcriptomic analysis of the development of LSEC-like cells is included, which will guide future studies to interrogate LSEC biology and produce LSEC-like cells which could be used for regenerative medicine.

Mr. PT is a 60-year-old male of South-East Asian background referred by his General Practitioner to the outpatient clinic for further investigation of iron deficiency anaemia. His past medical history includes laparoscopic cholecystectomy for gallstone pancreatitis, asthma, hypercholestrolaemia and allergic rhinitis. In the months following referral, he was twice admitted to hospital with generalized abdominal pain and non-bilious vomiting. His lipase was elevated on his first admission to 940 IU/L (normal range 13–60 IU/L) and liver function tests were consistent with mild biliary obstruction. On admission, his ALT was 569 IU/L (normal range 5–40), GGT 817 (normal range 10–71), ALP 719 (normal range 30–110) and bilirubin 12 (normal range 2–20). These episodes of pain and vomiting resolved with conservative management. An initial computed tomography of the abdomen showed an irregular circumferential wall thickening extending from the pylorus to the third part of the duodenum suggestive of duodenal intussusception (Fig. 1). Subsequent magnetic resonance imaging again demonstrated a proximal duodenal soft tissue lesion with intussusception. Mr. PT was referred for a gastroscopy, which revealed an ulcerated polypoid duodenal mass larger than 50 mm in size, in the first and second parts of the duodenum. The exact position of the base of the polyp was unable to be determined at endoscopy, however it was proximal to the major papilla (Fig. 2). Endoscopic

INTRODUCTION:Pancreatic neuroendocrine tumours (PNETs) are heterogenous entities with variable clinical outlook. The prevalence of PNETs is increasing in Australia. Despite this, data on peri-operative management and post-operative prognosis for Australian patients is scant in the literature.METHODS:Patients from two tertiary hospitals in Victoria were recruited. Inclusion criteria included patients who underwent curative surgical resection for primary, non-functioning, PNETs without metastases from January 2011 to December 2021. Patients were identified via histopathological reports, CMBS and ICD-10 codes. Data were sourced from Electronic Medical Records, outpatient notes and letters.RESULTS:Sixty-three patients (34 Male, 29 Female) underwent surgical resection for PNETs. Fifty-three patients (84.1%) had a post-operative complication, and 21 (33.3%) had severe complications. Two patients had disease recurrence. Head PNETs had higher Ki-67% (5.33 vs. 2.72, P = 0.29), and likelihood of nodal spread (9 (36%) vs. 4 (16%), P = 0.054). Pancreatic Head resections were also associated with more frequent ICU admissions (21 (84%) vs. 18 (54.5), P = 0.024), longer ICU stays (4.05 vs. 2.17 days, P = 0.10) and hospital stays (26.76 vs. 8.27 days, P = <0.001).CONCLUSION:Within the limitations of this study, it demonstrates that surgical resection of PNET carries a significant morbidity with a low rate of recurrence. Additionally, Pancreatic head NETs may be associated with higher grades and increased likelihood of nodal metastases. Considering this, careful patient selection is paramount.

BACKGROUND:Subtotal cholecystectomy is utilized in conditions of high risk to critical structures, like the common bile duct. However, the remnant gall bladder may become symptomatic and require a completion cholecystectomy for treatment. This second procedure can itself be a risk to critical structures. To establish the incidence of redo-cholecystectomy and identify risk factors that lead to subtotal cholecystectomy and repeat operation in a review of state-based practices for cholecystectomy.METHODS:A search of state coding records relating to cholecystectomy from 1998 to 2016. Patients who were coded for cholecystectomy-related procedures on different dates were identified. Patients who underwent the procedures within 6 months were excluded to avoid acute post-operative complications and gall bladder malignancy.RESULTS:210 719 cholecystectomies were performed. 1133 required repeat procedure. 616 were excluded, leaving 516 (0.25%) cholecystectomy patients requiring a second cholecystectomy. The subsequent operation was more likely to be an emergency procedure; involve transcystic bile duct exploration, adhesiolysis and require intensive care unit admission post-operatively. A repeat cholecystectomy was more likely to occur after having the primary procedure at a public hospital and when an intra-operative cholangiogram was not performed. Over the study period, the rate of repeat cholecystectomy increased from 0.02% to 0.6%. Incidentally, the rate of intra-operative cholangiogram during a primary cholecystectomy increased from 43% to 73%.CONCLUSIONS:Repeat cholecystectomy is an uncommon procedure. A second cholecystectomy is a more complex and likely to require intensive care unit support. Referral to a tertiary hepatobiliary unit is recommended.

Background: Uveal melanoma (UM) is a rare malignancy with a propensity for metastasis to the liver. Systemic chemotherapy is typically ineffective in these patients with liver metastases and overall survival is poor. There are no evidence-based guidelines for management of UM liver metastases. The aim of this study was to review the evidence for management of UM liver metastases. Methods: A systematic review of English literature publications was conducted across Ovid Medline, Ovid MEDLINE and Cochrane CENTRAL databases until April 2019. The primary outcome was overall survival, with disease free survival as a secondary outcome. Results: 55 studies were included in the study, with 2446 patients treated overall. The majority of these studies were retrospective, with 17 of 55 including comparative data. Treatment modalities included surgery, isolated hepatic perfusion (IHP), hepatic artery infusion (HAI), transarterial chemoembolization (TACE), selective internal radiotherapy (SIRT) and Immunoembolization (IE). Survival varied greatly between treatments and between studies using the same treatments. Both surgery and liver-directed treatments were shown to have benefit in selected patients. Conclusion: Predominantly retrospective and uncontrolled studies suggest that surgery and locoregional techniques may prolong survival. Substantial variability in patient selection and study design makes comparison of data and formulation of recommendations challenging.

Background Extended venothromboprophylaxis (eVTP) after abdominal surgery for hepatobiliary (HPB) and upper gastrointestinal (UGI) malignancies is recommended. Safety, efficacy and compliance within this group of surgical patients are not well described. The primary aim was to assess safety and compliance of post‐operative administration of eVTP with low molecular weight heparin. Secondary aim was to assess barriers to treatment and monitor the rate of post‐operative venous thromboembolism. Methods A prospective observational cohort study of patients undergoing abdominal surgery for HPB or UGI malignancies was undertaken from January 2014 to June 2016. All patients were assessed for eVTP. Demographics, clinical outcomes and clinical questionnaires on discharge and at follow‐up 6 weeks post their initial surgery were used to assess the safety, compliance and efficacy of eVTP. Results A total of 100 patients were assessed for post‐operative eVTP. Of these, 80 patients were prescribed 28 days of low molecular weight heparin. Of 80 patients, 65 (85%) patients completed the full eVTP, 11 (13%) missed 1–5 injections and only four (6%) missed 6–15 injections. In the 80 eVTP patients, there were no episodes of significant bleeding or venous thromboembolism. A total of nine (11%) patients would be unwilling to undertake eVTP again for a variety of reasons, including ease of disposal of syringes and needle phobias. Conclusion The administration of eVTP in patients undergoing major HPB and UGI surgery is safe, with minimal morbidity and high compliance. The greatest barrier to administration is doctor prescription.

The vagrant liver is a rare condition due to laxity or inadequate formation of the coronary and triangular ligaments which normally contribute to its fixation and has been associated with colonic redundancy and hypermobility. We present a case of a gallstone pancreatitis in an adult patient with hepato-pancreato-biliary heterotopia secondary to omphalocoele which was repaired at birth. A 72-year-old woman presented with a 1-day history of left upper quadrant pain without radiation. Her past surgical history included omphalocoele repair at birth and small bowel resection for bowel obstruction 50 years ago. Medical comorbidities included chronic bronchitis and hypertension. Upon admission, she was afebrile and haemodynamically stable with percussive tenderness in her epigastric region. Her initial white cell count was 32 × 10/L, lipase was 3000 U/L, bilirubin was 29 μmol/L and a diagnosis of mild acute pancreatitis was made. An ultrasound scan showed sludge within the gallbladder and a 5-mm common bile duct (CBD) but did not reveal choledocholithiasis. A computed tomography scan was performed which revealed uncomplicated pancreatitis and delineated her abnormal anatomy which includes a displaced liver located centrally within the abdomen with a 5-cm long common hepatic vein which tethers the inferior vena cava anteriorly, an intra-peritoneal pancreas and non-rotation of the colon with loops of small and large intestine filling the right subdiaphragmatic space (Fig. 1). Magnetic resonance cholangio-pancreatography revealed an inverted biliary tree with choledocholithiasis (Fig. 2). She underwent endoscopic retrograde cholangio-pancreatography (ERCP). This was performed under propofol sedation by an anaesthetist with intravenous tazocin and rectal indomethacin given prior to the procedure. Due to her history of bronchitis, she was unable to tolerate the usual prone position and the ERCP was performed in the supine position. The sphincter of Oddi was catheterized and initial guide-wire insertion revealed a cranial trajectory, which was recognized as entering the pancreatic duct. The wire was subsequently repositioned to obtain a caudal/transverse trajectory prior to confirming cannulation of the inverted CBD with the injection of contrast via a sphincterotome cannula. A routine sphincterotomy was performed and a 6-mm CBD stone was extracted using a 12-mm balloon (Fig. 3). The patient recovered with no complications and was discharged the following day after declining immediate cholecystectomy. Although it is unlikely that this patient’s hepato-pancreato-biliary heterotopia increased her risk of gallstone pancreatitis, her uncommon anatomy highlighted some interesting considerations to this common diagnosis. Her initial examination revealed epigastric peritonism presumably due to the intraperitoneal location of her pancreas, a finding atypical for mild pancreatitis. During the ERCP to clear the CBD, careful consideration of the patient’s altered anatomy decreased her risk of post-ERCP pancreatitis by avoiding contrast-injection into the pancreatic duct. Although this patient declined immediate cholecystectomy, an operation will likely require an open lower abdominal approach. An omphalocoele is a rare congenital defect due to the failure of abdominal organs returning into the abdominal cavity during the 10th week of intrauterine life. Therefore at birth, the intestines and

BackgroundBalloon dilatation of the ampulla at endoscopic retrograde cholangiopancreatography (ERCP) is increasingly utilized in the management of large bile duct stones. The aim of this study was to review and compare the outcomes of using endoscopic sphincterotomy with endoscopic balloon dilatation (sphincteroplasty) in a combined approach as a single-stage (immediate) or a two-stage procedure (delayed).MethodsA retrospective review of medical records for all patients undergoing ERCP and balloon dilatation for choledocholithiasis between January 2010 and December 2012 was undertaken. Outcomes measured included patient demographics, stone size, degree of dilatation performed, success of stone extraction, number of procedures required for duct clearance and procedure-related complications.ResultsOne hundred and thirty-six ERCPs were performed with balloon sphincteroplasty. One hundred and four had a previous sphincterotomy with a delayed balloon dilatation and 32 had sphincterotomy with immediate dilatation. The overall clearance rate of the common bile duct for immediate and delayed groups was 93% (28/30) and 93% (81/87), respectively. Bile duct clearance after the first procedure was achieved in 70% (21/30) of patients in the immediate group and 74% (64/87) in the delayed group. There were six complications in the delayed group and four in the immediate group. The most frequently used balloon size was 10 mm for both groups with mean sizes of 10.34 (2.93) and 11.73 (2.87) in the immediate and delayed groups, respectively.ConclusionOur study suggests that use of a combined approach is safe and effective and may provide benefits over using endoscopic balloon dilatation or endoscopic sphincterotomy alone in the treatment of choledocholithiasis.

epididymis, which is derived from the mesonephric duct. This structure persists in the male embryo, where it develops into the epididymis, vas deferens and ejaculatory duct under the influence of testosterone. Thus, it would seem to be a more likely progenitor than the paramesonephric duct in males. The more dorsal and medial position of the mesonephric ducts in the embryo may render them less susceptible to being entrapped by the developing limb bud, which could explain the much lower incidence of these cysts in males. It is impossible to separate mesonephric from paramesonephric origin using the immunohistochemical panel employed here and in previous studies. In summary, we have described an example of a cutaneous ciliated cyst occurring in the scrotum of a male. In our case the morphology and immunoprofile of the cyst lining was similar to both the appendix of the epididymis and the appendix of the testis, strongly suggesting that it was derived from one of the genital ducts, rather than from an eccrine structure with ciliated metaplasia. Given the morphological and immunohistochemical similarities, we raise the novel hypothesis that origin from the mesonephric duct may explain some examples of these cysts when they occur in males.

BACKGROUND:Chemotherapy has in some series been linked with increased morbidity after a hepatectomy. Hepatic injuries may result from the treatment with chemotherapy, but can also be secondary to co-morbid diseases. The aim of the present study was to draw correlations between clinical features, treatment with chemotherapy and injury phenotypes and assess the impact of each upon perioperative morbidity.PATIENTS AND METHODS:Retrospective samples (n= 232) were scored grading steatosis, steatohepatitis and sinusoidal injury (SI). Clinical data were retrieved from medical records. Correlations were drawn between injury, clinical features and perioperative morbidity.RESULTS:Injury rates were 18%, 4% and 19% for steatosis, steatohepatitis and SI, respectively. High-grade steatosis was more common in patients with diabetes [odds ratio (OR) = 3.33, P= 0.01] and patients with a higher weight (OR/kg = 1.04, P= 0.02). Steatohepatitis was increased with metabolic syndrome (OR = 5.88, P= 0.02). Chemotherapy overall demonstrated a trend towards an approximately doubled risk of high-grade steatosis and steatohepatitis although not affecting SI. However, pre-operative chemotherapy was associated with an increased SI (OR = 2.18, P= 0.05). Operative morbidity was not increased with chemotherapy, but was increased with steatosis (OR = 2.38, P= 0.02).CONCLUSIONS:Diabetes and higher weight significantly increased the risk of steatosis, whereas metabolic syndrome significantly increased risk of steatohepatitis. The presence of high-grade steatosis increases perioperative morbidity, not administration of chemotherapy per se.

We read with interest the retrospective case series review of McLeish et al. in the Jan/Feb issue. While we agree with the authors that fluorodeoxyglucose-positive emission tomography (FDG-PET) with or without computed tomography (CT) is highly sensitive and specific for colorectal tumours, we have some concerns regarding their conclusions about its role in the intrahepatic staging of colorectal liver metastases (CRLM). The study makes several assumptions that do not reflect current assessment of CRLM. (i) The statement that ‘demonstrable extrahepatic disease’ is a contraindication to CRLM resection is false. Many large retrospective series demonstrate long-term survival if both liver and extrahepatic can be resected and the presence of resectable extrahepatic disease is not an absolute contraindication for liver resection. (ii) An assessment of the impact of PET on management is made without a formal comparison of imaging, and without the involvement of a hepatobiliary surgeon to assess resectability. For example, figure 3 demonstrates an additional CRLM detected on PET that is said to prohibit resection. The PET imaging has been compared with a non-contrast CT scan of the liver and on the basis of the PET image would still be resectable. (iii) Pathological confirmation of the PET findings and whether the patients went on to have any surgery has not been reported. We query the study findings especially the high ‘impact’ on management. In terms of FDG-PET intrahepatic staging of CRLM there are few prospective studies. In fact, a systematic review has shown superior detection and characterization of CRLM by magnetic resonance imaging (MRI) with contrast compared with FDG-PET on a per lesion basis. The main role of a pretreatment FDG-PET scan is to detect unresectable extrahepatic metastases, and for this reason we recommend routine use of FDG-PET prior to chemotherapy or surgery. For accurate intrahepatic staging we recommend contrast-enhanced liver MRI.

Background: A standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established. Methods: An international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management. Results: The definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level >3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/ or re-laparotomy defines Grade C PHH. Conclusion: The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications.

ObjectiveBile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries.MethodsA retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion.ResultsControlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen.ConclusionsThis review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

Chemotherapy is being administered to an increasing number of patients with colorectal liver metastases (CRLM), whether they have resectable disease or not. Although this may be appropriate to downstage patients with unresectable disease, and offers theoretical advantages to those who have resectable disease, there is a price to be paid in the development of chemotherapy-induced hepatic injuries (CIHI). These include chemotherapy-associated fatty liver diseases and sinusoidal injuries. The main chemotherapeutic agents currently used in the adjuvant setting for colorectal carcinoma, and the neoadjuvant treatment of CRLM include 5-flurouracil, oxaliplatin and irinotecan, and while there are non-specific and overlapping injury profiles, oxaliplatin does appear to be primarily associated with sinusoidal injury and irinotecan with steatohepatitis. In this review, the rationale for administering chemotherapy to patients with CRLM is presented, and the problems this brings are outlined. The specific injury patterns will be detailed, as well as the data correlating specific chemotherapy regimens to these injury patterns. Finally, the clinical outcomes of patients with CRLM who undergo neoadjuvant chemotherapy followed by hepatic resection will be considered. The need for methods to identify patients at risk of CIHI and to recognize established CIHI prior to surgery will be emphasized.

Background. Despite the potentially severe impact of bile leakage on patients' pen operative and long-term outcome, a commonly used definition of this complication after hepatobiliary and pancreatic operations has not yet been established. The aim of the present article is to propose a uniform definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy.Methods. An international study group of hepatobiliary and pancreatic surgeons was convened. A consensus definition of bile leakage after hepatobiliary and pancreatic operative therapy was developed based on the postoperative course of bilirubin concentrations in patients' serum and drain fluid.Results. After evaluation of the postoperative course of bilirubin levels in the drain fluid of patients who underwent hepatobiliary and pancreatic operations, bile leakage was defined as bilirubin concentration in the drain fluid at least 3 times the serum, bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis. Using this criterion severity of bile leakage was classified according to its impact on patients' clinical management. Grade A bile leakage causes no change in patients' clinical management. A Grade B bile leakage requires active therapeutic intervention but is manageable without relaparotomy, whereas in Grade C, bile leakage relaparotomy is required.Conclusion. We propose a simple definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy. The application of the present proposal will enable a standardized comparison of the results of different clinical trials and may facilitate an objective evaluation of diagnostic and therapeutic modalities in the field of hepatobiliary and pancreatic operative therapy. (Surgery 2011;149:680-8.)

Background: A standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established.Methods: An international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management.Results: The definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level >3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/or re-laparotomy defines Grade C PHH.Conclusion: The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications.