Are There Better Guidelines for Allocation in Liver Transplantation?: A Novel Score Targeting Justice and Utility in the Model for End-Stage Liver Disease Era^-www.drkeyurbhatt.in*

Annals of Surgery:

November 2011 - Volume 254 - Issue 5 - p 745–754

doi: 10.1097/SLA.0b013e3182365081

Original Article From the ESA Proceedings

Dutkowski, Philipp MD*; Oberkofler, Christian E. MD*; Slankamenac, Ksenija MC*; Puhan, Milo A. MD‡; Schadde, Erik MD*; Müllhaupt, Beat MD†; Geier, Andreas MD†; Clavien, Pierre A. MD, PhD*

Abstract

Objectives: To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.

Background: The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

Methods: Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone.

Results: Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population.

Conclusions: The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.

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Influence of Surgical Margins on Outcome in Patients With Intrahepatic Cholangiocarcinoma: A Multicenter Study by the AFC-IHCC-2009 Study Group^-www.drkeyurbhatt.in*

Annals of Surgery:

November 2011 - Volume 254 - Issue 5 - p 824–830

doi: 10.1097/SLA.0b013e318236c21d

Original Article From the ESA Proceedings

Farges, Olivier MD, PhD*; Fuks, David MD†; Boleslawski, Emmanuel MD‡; Le Treut, Yves-Patrice MD§; Castaing, Denis MD¶; Laurent, Alexis MD‖; Ducerf, Christian MD**; Rivoire, Michel MD††; Bachellier, Philippe MD‡‡; Chiche, Laurence MD§§; Nuzzo, Gennaro MD¶¶; Regimbeau, Jean Marc MD†

Abstract

Objective: Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC).

Background Data: Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated.

Methods: We studied 212 patients undergoing curative resection of mass-forming–type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latter's components were evaluated.

Results: Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7–2.1)] in contrast to the pTNM stage [OR 2.10 (1.2–3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5–20.4)], as was the presence of satellite nodules [OR 1.9 (1.1–3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤1 mm: 15 months; 2–4 mm: 36 months; 5–9 mm: 57 month; ≥10 mm: 64 month, P < 0.001) and a margin >5 mm was an independent predictor of survival [OR 2.22 (1.59–3.09)].

Conclusion: Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low.

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CASE: Chronic pancreatitis (idiopathic) - LPJ^-www.drkeyurbhatt.in*

young girl with chronic abdominal pain for last 2 yrs
Diagnosed with chronic pancreatitis (? idiopathic ? tropical variety)
CECT:

SURGERY: LPJ (with head coring )

discharged on POD 5.


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Endoscopic and Surgical Treatments for Achalasia: A Systematic Review and Meta-Analysis^-www.drkeyurbhatt.in*

Annals of Surgery:

January 2009 - Volume 249 - Issue 1 - pp 45-57

doi: 10.1097/SLA.0b013e31818e43ab

Meta-Analysis

Abstract

Background: Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.

Objective: To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.

Methods: A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.

Results: A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).

Conclusions: EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

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CASE: Hiatus hernia with gastric volvuous - lap reduction, fundoplication, retrocolic seromascular GJ (fixation)^-www.drkeyurbhatt.in*

60 yrs female with recurrent gastric volvulous for last 5 yrs with eventration of diaphragm and large hiatus hernia:

SURGERY: Lap. Nissan's floppy fundoplication + retrocolic stomach fixation with jejunum.

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