Showing papers by "Vincent W. T. Lam published in 2016"

Percutaneous vs. endoscopic pre-operative biliary drainage in hilar cholangiocarcinoma – a systematic review and meta-analysis

Abstract: Background The strategy for preoperative management of biliary obstruction in hilar cholangiocarcinoma (HCCA) patients with regards to drainage by endoscopic (EBD) or percutaneous (PTBD) methods is not clearly defined. The aim of this study was to investigate the utility, complications and therapeutic efficacy of these methods in HCCA patients, with a secondary aim to assess the use of portal vein embolization (PVE) in patients undergoing drainage.

Improving psychosocial outcomes for caregivers of people with poor prognosis gastrointestinal cancers: a randomized controlled trial (Family Connect).

Abstract: This study investigated the effectiveness of a structured telephone intervention for caregivers of people diagnosed with poor prognosis gastrointestinal cancer to improve psychosocial outcomes for both caregivers and patients. Caregivers of patients starting treatment for upper gastrointestinal or Dukes D colorectal cancer were randomly assigned (1:1) to the Family Connect telephone intervention or usual care. Caregivers in the intervention group received four standardized telephone calls in the 10 weeks following patient hospital discharge. Caregivers’ quality of life (QOL), caregiver burden, unmet supportive care needs and distress were assessed at 3 and 6 months. Patients’ QOL, unmet supportive care needs, distress and health service utilization were also assessed at these time points. Caregivers (128) were randomized to intervention or usual care groups. At 3 months, caregiver QOL scores and other caregiver-reported outcomes were similar in both groups. Intervention group participants experienced a greater sense of social support (p = .049) and reduced worry about finances (p = .014). Patients whose caregiver was randomized to the intervention also had fewer emergency department presentations and unplanned hospital readmissions at 3 months post-discharge (total 17 vs. 5, p = .01). This standardized intervention did not demonstrate any significant improvements in caregiver well-being but did result in a decrease in patient emergency department presentations and unplanned hospital readmissions in the immediate post-discharge period. The trend towards improvements in a number of caregiver outcomes and the improvement in health service utilization support further development of telephone-based caregiver-focused supportive care interventions.

A pre-operative clinical model to predict microvascular invasion and long-term outcome after resection of hepatocellular cancer: The Australian experience.

Abstract: Background Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI). Methods Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified. Results The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI. Conclusion MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

Use of the harmonic scalpel in cold phase recovery of the pancreas for transplantation: the westmead technique.

Abstract: Dear Editors, Pancreatic transplantation for the treatment of type I diabetes offers the current gold standard treatment for a previously incurable disease [1]. During our extensive experience with en bloc liver and pancreas recoveries, we noted the time-consuming nature of individually dividing vessels along the greater curvature of the stomach, in addition to dissection of the superior mesenteric pedicle close to the root of the small bowel mesentery. Additionally, small vessels around the pancreatic graft borders are often missed during cold phase dissection and are thus likely sources of blood loss during organ reperfusion in the recipient [2]. The ultrasonically activated Harmonic Scalpel (Smithfield, RI, USA) uses high-frequency ultrasound vibrations to cut and coagulate tissue [3]. The mechanical energy at the tip of the shear results in the denaturation of proteins, which then form a coagulum to produce haemostasis [3]. Direct comparisons between the Harmonic Scalpel (HS) and electrocautery have shown that the HS is associated with reduced operative time and bleeding [4,5]. Herein, we describe easily adaptable modifications to the en bloc technique incorporating pancreas recovery using the HS that allows for more timely and effective procurement of the organ; to our knowledge, the use of the HS has not yet been described for this procedure. The standard technique for procurement of the pancreas for transplantation has been described in detail previously [6–8]. Our HS modification [the modified (Westmead) technique] to the standard recovery technique can be divided into in situ and ex situ phases. In situ, the instrument is used for dissection around the greater curvature of the stomach, including division of the short gastric vessels. The HS is further utilized in mobilizing the splenic flexure of the colon, which is often surrounded by diffuse fatty and vascular tissue. This enables almost bloodless dissection down onto the pancreas and lower pole of the spleen and facilitates rapid skeletonization of the pancreas to allow its mobilization to the midline. Following perfusion within the cold phase of dissection, the HS allows the sealing of small jejunal branches, facilitating the rapid and safe creation of a more defined superior mesenteric artery (SMA) and vein (SMV) pedicle inferior to the pancreatic head (Fig. 1a). This pedicle can then be easily and safely ligated with the single deployment of a vascular stapler, while ensuring minimal vessel leakage in the recipient. Complete en bloc removal of the liver–pancreas block then proceeds in a standard fashion. Ex situ, the HS can also effectively be employed on the back-table for further clearing of extraneous tissues from the pancreas. We first use the device to separate the pancreas from the spleen via division of the splenorenal ligament. The splenic artery and vein are individually ligated with sutures, having skeletonized the vessels using the HS technique. It is then utilized for the removal of any remaining/excess fatty tissue around the body and tail of the pancreas, such that there is no further adherent tissue requiring removal at the recipient centre. We believe that the quality of the final recovered organ is significantly superior compared to cases when the HS is not employed

Response to Re: Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta-analysis.

Abstract: It is with great respect that I reflect on the comments made by Kehlet and Su’a and Hill on our paper. The limitations highlighted by these experts are acknowledged along with the value of their perspectives. Our intention was to provoke thought and stimulate discussion in an area of interest for those who perform colorectal surgery. The intention was also to be honest about what happens in many units, but it is not openly discussed (D’Souza, pers. comm., 2015). The science referenced provides a clear picture. The greater challenge, however, lies in wider translation of the science. Under ideal circumstances, we would be able to do things differently, but in the meantime, we do the best we can, respecting the wisdom of those who lead and guide.