Whipple’s Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience

Introduction. Whipple’s pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple’s PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child’s A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child’s B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. Conclusion. Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple’s PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

BackgroundOutpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines.MethodsThis is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines.ResultsIn total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed.ConclusionThe salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.

Clinical-Radiomic Analysis for Pretreatment Prediction of Objective Response to First Transarterial Chemoembolization in Hepatocellular Carcinoma

<b><i>Background:</i></b> The preoperative selection of patients with intermediate-stage hepatocellular carcinoma (HCC) who are likely to have an objective response to first transarterial chemoembolization (TACE) remains challenging. <b><i>Objective:</i></b> To develop and validate a clinical-radiomic model (CR model) for preoperatively predicting treatment response to first TACE in patients with intermediate-stage HCC. <b><i>Methods:</i></b> A total of 595 patients with intermediate-stage HCC were included in this retrospective study. A tumoral and peritumoral (10 mm) radiomic signature (TPR-signature) was constructed based on 3,404 radiomic features from 4 regions of interest. A predictive CR model based on TPR-signature and clinical factors was developed using multivariate logistic regression. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the model’s performance. <b><i>Results:</i></b> The final CR model consisted of 5 independent predictors, including TPR-signature (<i>p</i> &#x3c; 0.001), AFP (<i>p</i> = 0.004), Barcelona Clinic Liver Cancer System Stage B (BCLC B) subclassification (<i>p</i> = 0.01), tumor location (<i>p</i> = 0.039), and arterial hyperenhancement (<i>p</i> = 0.050). The internal and external validation results demonstrated the high-performance level of this model, with internal and external AUCs of 0.94 and 0.90, respectively. In addition, the predicted objective response via the CR model was associated with improved survival in the external validation cohort (hazard ratio: 2.43; 95% confidence interval: 1.60–3.69; <i>p</i> &#x3c; 0.001). The predicted treatment response also allowed for significant discrimination between the Kaplan-Meier curves of each BCLC B subclassification. <b><i>Conclusions:</i></b> The CR model had an excellent performance in predicting the first TACE response in patients with intermediate-stage HCC and could provide a robust predictive tool to assist with the selection of patients for TACE.

Applicability of cone beam computed tomography gray values for estimation of primary stability of dental implants

Objective: To evaluate the relationship between bone density measured by computed tomography (CT) and cone beam computed tomography (CBCT) (Sirona’s Galileos scanner) with primary stability of dental implants. Material and methods: 20 fresh bovine femoral heads were prepared by removal of soft tissue, sectioning of the bone, and placement of markers for location and angulation of implants. Bone density of peri-implant areas was determined preoperatively by CT and CBCT scanning of the prepared bone samples represented by Hounsfield units (HUs) and gray values (GVs), respectively. Then, 60 implants in three sizes (diameter = 4 mm, length = 8, 10, and 12 mm) were inserted into the bones and maximum insertion torque (IT) was recorded. Osstell device was also used for determining the implant stability quotient (ISQ) for each implant. Statistical analysis was performed on the data (alpha = 0.05). Results: Mean ± SD values of GV, HU, and ISQ were 1592.75 ± 231.82, 675.26 ± 115.38 and 61.90 ± 10.14, respectively. Moreover, the most frequent IT limit was 30-35 Ncm (41.4%). Significant relationships were observed between HU and IT, GV and IT, HU and ISQ, GV and ISQ, and IT and ISQ in all implant sizes. Moreover, GV and HU also significantly correlated to each other. Conclusion: Bone density values in CBCT and CT scans are positively associated to primary stability of dental implants. Therefore, GVs obtained from Galileos CBCT scanner can be used for preoperative selection of edentulous sites which allow for better implant stability or locations which require further procedures for enhancing the success rate of dental implants. KEYWORDSComputed tomography; Cone beam computed tomography; Dental implant.

Submental Artery Island Flap in Oral Cavity Reconstruction. An Observational, Retrospective Two-centre Study

Introduction The submental flap provides an alternative technique in orofacial reconstruction, especially in situations in which free flaps are not available, or the patients are unfit. Objective To demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction. Methods A total of 14 patients with oral cavity cancers, who underwent submental flap reconstruction from January 2016 to January 2018, were included in the study. Results There were 11 male and 3 female patients with a mean age of 66.7 ± 14 (Min: 52/Max: 91) years old. The most common primary tumor site was the mobile tongue in 12 (85.7%) patients. All of the patients underwent ipsilateral selective neck dissection after the flap was harvested. Flap partial necrosis was observed in one patient, and total necrosis in another one. The mean follow-up was of one year. Nonlocal or regional recurrences were observed. Conclusion Submental island flap represents a good option in oral cavity reconstruction in a restricted setting or in patients considered not fit for free flap reconstruction. Preoperative selection of clinically neck node-negative patients is essential due to the potential risk of occult metastasis.

Mortality risk factors in lobectomies: Single-institution study

The need to identify the risk factors (RFs) predictive of mortality after pulmonary lobectomy has fuelled several single- or multi-institution studies, without establishing a prediction model of the generally accepted risk. Each single-institution study offers its own RFs, which corroborated with the RFs published in other multicentric studies may allow a better prediction of postoperative mortality for specific categories of patients. The aim of our study was to identify the 30-day mortality RFs in our lobectomy patients and to compare our results with those published in literature. We therefore analysed the influence of 49 perioperative parameters on postoperative mortality of consecutive lobectomy patients. The 192 lobectomy patients enrolled had malignant (81.25%) and infectious conditions (12.5%) and a 2.6% mortality rate. The results of our study support the following perioperative RF associated with a high mortality rate: thrombocytosis, chronic obstructive bronchopulmonary disease (COPD), digestive and hepatic comorbidities, neoadjuvant chemotherapy, tuberculosis, the American Society of Anesthesiologists rating and the characteristics of postoperative drainage. In conclusion, these RFs may serve as the factors to consider when calculating the mortality rate after lobectomy, in preoperative selection as well as in instruments for the assessment of postoperative results.

The role of vascular reconstructions in surgery of tumors of the hepatopancreatobiliary zone

According to the point of view that has been dominating for many years, pancreatoduodenal resection was indicated only for localized tumors of the pancreas without involvement of the major vessels. In view of the prevalence of this pathology, many authors have recently pointed out the need to perform resection of a pancreatic tumor in a single bloc with the vessels involved, which gives a chance to increase the resectability in a larger number of patients. Aim. Analysis of resectability of pancreatic tumors on the basis of the data of current clinical research. In recent decades many different surgical approaches have been improved which increases chances for successful and safe surgical intervention. The data of the analysis of literature on vascular reconstructions in surgery for tumors of the hepatopancreatobiliary zone showed that resections and reconstructions of the mesenteric portal venous segment permit to increase resectability of tumor and should correspond to the fundamental principles of surgical oncology. To date, in terms of the incidence of postoperative complications and mortality, no statistically significant differences were found between the group of patients in whom vascular resection was performed, and the group with a standard pancreatoduodenal resection. A thorough preoperative selection of patients along with the correct strategy of venous reconstruction is equally important for correct and successful resection of the blood vessels en bloc.