In recent years, great progress has been made toward safer hepatobiliary surgical interventions. This has resulted in more widely available treatments for patients who in the past were ineligible for curative resection of primary liver tumors, liver metastases, and advanced biliary tumors. However, the rise in procedures has seen increasingly heterogeneous perioperative management, yielding strikingly disparate outcomes. A number of groups have attempted to standardize perioperative care in an effort to create enhanced recovery pathways (ERPs) and provide clinicians with a dependable roadmap to success following hepatectomy. In the future, each aspect of perioperative care could be pre-ordained with emphasis on nutrition, anesthesia, prophylaxis, use of surgical drains, post-operative fluid and electrolyte management, and contact with physician extenders following discharge. This article reviews the data behind ERPs preceding and following hepatectomy. It includes primary data justifying practices in post-hepatectomy support. It also touches on the benefits of minimally invasive hepatectomy and offers future directions for research in peri-hepatectomy ERPs. Overall, this article seeks to formulate a pathway for practice based on data, with enough details to allow creation of rational order sets for efficient and superior practice.

BACKGROUND AND OBJECTIVES:Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation. METHODS:Faculty were identified from accredited surgical oncology fellowships in the United States. Scopus was used to obtain the number of publications/citations and h-index values. The National Institutes of Health (NIH) RePORT website was used to identify funding history. RESULTS:Of the 319 surgeons identified, complete rank information was obtained for 308. The majority of faculty were men (70%) and only 11% of full professors were women. The median h-index values were 7, 17, and 39 for assistant, associate, and full professors, respectively. While 50% of full professors had a history of NIH funding, only 26% had RO1s and 20% had current NIH funding. Using multivariate analysis, years in practice, h-index, and a history of NIH funding were associated with academic rank (P < .05). CONCLUSION:Objective benchmarks, such as the median h-index and NIH funding, provide additional insights for both junior faculty and leadership into the productivity needed to attain promotion to the next academic rank for surgical oncologists.

Background

Fibrolamellar hepatocellular carcinoma (FLHC) is a unique entity compared to conventional hepatocellular carcinoma. The aim of this study was to examine post-resection outcomes and prognostic indicators for survival in this group of FLHC patients.

Methods

A retrospective analysis of the National Cancer Database (NCDB) for patients with FLHC who underwent resection from 2004 to 2014 was performed. Univariate and multivariate Cox proportional hazard models were used to identify factors associated with overall survival, and a prognostic nomogram was generated.

Results

There were 197 patients identified, 171 (86.8%) of whom had long-term follow-up data. Univariate and multivariate analyses were performed using patient and tumor demographics with the outcome variable of overall survival. On multivariate analysis, age [hazard ratio (HR) 1.03, P=0.003], vascular invasion (HR 1.75, P=0.05), tumor size >7 cm (HR 2.18, P=0.044), multifocal disease (HR 3.34, P=0.002), and node positive (pN+) disease (HR 2.75, P=0.003) were all negative predictors of overall survival. A prognostic nomogram was generated using these factors with a c-statistic superior to that of American Joint Committee on Cancer (AJCC) staging (0.710 vs. 0.654).

Conclusions

Independent predictors of decreased overall survival in patients with FLHC include age, vascular invasion, tumor size >7 cm, multifocal disease, and pN+ disease. This is the first study to develop a nomogram exclusively for FLHC that may predict survival in future studies.

BACKGROUND:Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving. METHODS:In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014. RESULTS:The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches. CONCLUSION:Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.

BACKGROUND: Despite evidence that liver resection improves survival in patients with colorectal cancer liver metastases (CRCLM) and may be potentially curative, there are no population-level data examining utilization and predictors of liver resection in the United States. METHODS: This is a population-based cross-sectional study. We abstracted data on patients with synchronous CRCLM using California Cancer Registry from 2000 to 2012 and linked the records to the Office of Statewide Health Planning Inpatient Database. Quantum Geographic Information System (QGIS) was used to map liver resection rates to California counties. Patient- and hospital-level predictors were determined using mixed-effects logistic regression. RESULTS: Of the 24 828 patients diagnosed with stage-IV colorectal cancer, 16 382 (70%) had synchronous CRCLM. Overall liver resection rate for synchronous CRCLM was 10% (county resection rates ranging from 0% to 33%) with no improvement over time. There was no correlation between county incidence of synchronous CRCLM and rate of resection (R2  = .0005). On multivariable analysis, sociodemographic and treatment-initiating-facility characteristics were independently associated with receipt of liver resection after controlling for patient disease- and comorbidity-related factors. For instance, odds of liver resection decreased in patients with black race (OR 0.75 vs white) and Medicaid insurance (OR 0.62 vs private/PPO); but increased with initial treatment at NCI hospital (OR 1.69 vs Non-NCI hospital), or a high volume (10 + cases/year) (OR 1.40 vs low volume) liver surgery hospital. CONCLUSION: In this population-based study, only 10% of patients with liver metastases underwent liver resection. Furthermore, the study identifies wide variations and significant population-level disparities in the utilization of liver resection for CRCLM in California.

Background and objectives

Primary liver sarcomas (PLS) are rare. Published series are limited by small numbers of patients.

Methods

We reviewed the National Cancer Database (2004-2014) for patients who underwent surgical resection of PLS.

Results

Of 237 patients identified, the majority were female (60.8%), with median age of 52 years. Histologies were: epithelioid hemangioendothelioma (n = 67), angiosarcoma (n = 64), leiomyosarcoma (n = 33), embryonal rhabdomyosarcoma (n = 31), carcinosarcoma (n = 16), giant cell sarcoma (n = 14), spindle cell sarcoma (n = 12). Ninety-seven (40.9%) patients underwent lobectomies or extended lobectomies, 41 patients (17.3%) underwent transplantation. Surgical margins were negative in 82.9%. Tumors were well differentiated in 11.3%. Histology type correlated with outcome with the best prognosis for epithelioid hemangioendothelioma (OS: not reached, similar for resection and transplantation) and the worst for angiosarcoma (OS:16.6 mo with resection; 6 mo with transplantation; P = 0.04). Resections with microscopically negative margins were associated with improved survival (58.7 vs 11.3 mo for positive margins; P < 0.001). Chemotherapy and radiation therapy were used in a minority of patients (32.9% and 4.3% respectively) with no improvement in outcomes.

Conclusions

Both hepatic resection and liver transplantation can be associated with long term survival for selected primary liver sarcomas such as epitheliod hemangioendotheliomas. Histology type and the ability to resect the tumor with negative margins correlate with outcomes and the decision to operate should be carefully weighed for subtypes with particularly dismal prognosis such as angiosarcomas.