Publications by authors named "Eduard Jonas"

57 Publications

Reply to "Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with propensity score matching" by Abe et al.

Dig Endosc 2021 Nov 27. Epub 2021 Nov 27.

Surgical Gastroenterology Unit, Department of Surgery, J45 OMB, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.

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http://dx.doi.org/10.1111/den.14204DOI Listing
November 2021

Letter comments re: Multi-agent neoadjuvant chemotherapy improves survival in early-stage pancreatic cancer: A NCDB analysis.

Eur J Cancer 2021 Oct 11;158:36-37. Epub 2021 Oct 11.

University of Cape Town Faculty of Health Sciences, Cape Town, South Africa.

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http://dx.doi.org/10.1016/j.ejca.2021.09.001DOI Listing
October 2021

Letter to the Editor: Comment on: Outcomes of Patients with Borderline Resectable Pancreatic Cancer Treated with Combination Chemotherapy.

J Gastrointest Cancer 2021 Sep 26;52(3):1188-1189. Epub 2021 Jun 26.

Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road Observatory, 7925, Cape Town, South Africa.

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http://dx.doi.org/10.1007/s12029-021-00656-4DOI Listing
September 2021

Endoscopic Stenting for Malignant Biliary Obstruction: Results of a Nationwide Experience.

Clin Endosc 2021 Sep 31;54(5):713-721. Epub 2021 May 31.

Department of Surgical and Perioperative Sciences, Umeå University, Umeå University Hospital, Umeå, Sweden.

Background/aims: Many unanswered questions remain about the treatment of malignant hilar obstruction. We investigated endoscopic stenting for malignant biliary strictures, as reported in a nationwide registry.

Methods: All endoscopic retrograde cholangiopancreatography (ERCP) procedures entered in the Swedish Registry of Gallstone Surgery and ERCP from January 2010 to December 2017 in which stenting was performed for malignant biliary stricture management were included in this study. Patency was estimated by determining the time to reintervention.

Results: Endoscopic stenting was performed for malignant stricture management in 4623 ERCP procedures, of which 1364 (29.5%) were performed for hilar strictures. Of the hilar strictures, 320 (23.5%) were intrahepatic strictures (Bismuth-Corlette III-IV). Adverse events were more common after hilar stenting than after distal stenting (17.2% vs. 12.0%, p<0.0001). The 6-month reintervention rate was 73.4% after hilar stenting compared with 55.9% after distal stenting (p<0.0001). The 6-month reintervention rates for Bismuth-Corlette types I, II, IIIa, IIIb, and IV were 70.4%, 75.6%, 90.0%, 87.5%, and 85.7%, respectively. In multivariate analysis, the risk for reintervention was three times higher after hilar stenting than after distal stenting (hazard ratio 3.47, 95% confidence interval 2.01-6.00, p<0.001).

Conclusion: This study with a relatively large patient cohort undergoing endoscopic stenting confirms that stenting for malignant hilar obstruction has more adverse events and lower patency than stenting for distal malignant obstruction.
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http://dx.doi.org/10.5946/ce.2021.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505180PMC
September 2021

Pancreatic trauma with main pancreatic duct injury.

J Hepatobiliary Pancreat Sci 2021 09 19;28(9):e42-e43. Epub 2021 May 19.

Surgical Gastroenterology Unit, Division of General Surgery, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa.

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http://dx.doi.org/10.1002/jhbp.973DOI Listing
September 2021

Comment on "Prognostic Factors of Survival After Neoadjuvant Treatment and Resection for Initially Unresectable Pancreatic Cancer".

Ann Surg 2021 12;274(6):e898-e899

Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, Cape Town, South Africa.

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http://dx.doi.org/10.1097/SLA.0000000000004877DOI Listing
December 2021

Neoadjuvant chemotherapy for non-metastatic pancreatic cancer.

J Hepatobiliary Pancreat Sci 2021 04 20;28(4):e13-e14. Epub 2021 Mar 20.

Surgical Gastroenterology Unit, Division of General Surgery Health Sciences Faculty, University of Cape Town, Cape Town, South Africa.

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http://dx.doi.org/10.1002/jhbp.935DOI Listing
April 2021

Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis.

HPB (Oxford) 2021 02 22;23(2):173-186. Epub 2020 Oct 22.

Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa. Electronic address:

Background: The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC.

Methods: A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC).

Results: Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery.

Conclusion: Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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http://dx.doi.org/10.1016/j.hpb.2020.09.022DOI Listing
February 2021

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication.

World J Gastrointest Endosc 2020 Oct;12(10):365-377

Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa.

Background: Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.

Aim: To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.

Methods: A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.

Results: One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21-84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% ( = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% ( = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% ( = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure ( = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.

Conclusion: EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.
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http://dx.doi.org/10.4253/wjge.v12.i10.365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579524PMC
October 2020

Factors leading to loss of patency after biliary reconstruction of major laparoscopic cholecystectomy bile duct injuries: an observational study with long-term outcomes.

HPB (Oxford) 2020 11 20;22(11):1613-1621. Epub 2020 Mar 20.

Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa. Electronic address:

Background: Small sample size and a lack of standardized reporting for patients requiring reconstruction for laparoscopic cholecystectomy bile duct injuries (LC-BDI) have limited investigation of factors contributing to loss of patency.

Methods: Using a prospective database, patient characteristics, pre-repair investigations, Strasberg-Bismuth level of injury, timing of reconstruction and postoperative complications were compared in successful index reconstruction and revision patients. Multivariate analysis was performed to determine independent predictors of loss of patency.

Results: Of 131 patients analysed, 103 had a successful index reconstruction and 28 required revision. There were no statistically significant differences in patient characteristics between the two groups. Days to referral and reconstruction were significantly different (p < 0.001, p = 0.001). Patients with incomplete biliary imaging more often required a revision (p < 0.001). The only independent predictor of loss of patency was incomplete depiction of the biliary tree prior to initial reconstruction (p = 0.035, OR 10.131, 95% CI 1.180-86.987). Primary and secondary patency were 98.1% and 96.4%, respectively with no differences in 30-day complications.

Conclusions: Incomplete depiction of LC-BDI before index reconstruction was independently associated with loss of patency requiring revision. Despite the complexity of repeat biliary reconstruction, outcomes in an HPB unit were similar to that of an index reconstruction.
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http://dx.doi.org/10.1016/j.hpb.2020.02.010DOI Listing
November 2020

Synchronous and metachronous liver metastases in patients with colorectal cancer-towards a clinically relevant definition.

World J Surg Oncol 2019 Dec 26;17(1):228. Epub 2019 Dec 26.

Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.

Background: Approximately 25% of patients with colorectal cancer (CRC) will have liver metastases classified as synchronous or metachronous. There is no consensus on the defining time point for synchronous/metachronous, and the prognostic implications thereof remain unclear. The aim of the study was to assess the prognostic value of differential detection at various defining time points in a population-based patient cohort and conduct a literature review of the topic.

Methods: All patients diagnosed with CRC in the counties of Stockholm and Gotland, Sweden, during 2008 were included in the study and followed for 5 years or until death to identify patients diagnosed with liver metastases. Patients with liver metastases were followed from time of diagnosis of liver metastases for at least 5 years or until death. Different time points defining synchronous/metachronous detection, as reported in the literature and identified in a literature search of databases (PubMed, Embase, Cochrane library), were applied to the cohort, and overall survival was calculated using Kaplan-Meier curves and compared with log-rank test. The influence of synchronously or metachronously detected liver metastases on disease-free and overall survival as reported in articles forthcoming from the literature search was also assessed.

Results: Liver metastases were diagnosed in 272/1026 patients with CRC (26.5%). No statistically significant difference in overall survival for synchronous vs. metachronous detection at any of the defining time points (CRC diagnosis/surgery and 3, 6 and 12 months post-diagnosis/surgery) was demonstrated for operated or non-operated patients. In the literature search, 41 publications met the inclusion criteria. No clear pattern emerged regarding the prognostic significance of synchronous vs. metachronous detection.

Conclusion: Synchronous vs. metachronous detection of CRC liver metastases lacks prognostic value. Using primary tumour diagnosis/operation as standardized cut-off point to define synchronous/metachronous detection is semantically correct. In synchronous detection, it defines a clinically relevant group of patients where individualized multimodality treatment protocols will apply.
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http://dx.doi.org/10.1186/s12957-019-1771-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933908PMC
December 2019

Medical Student And Faculty Perceptions Of Undergraduate Surgical Training In The South African And Swedish Tertiary Institutions: A Cross-Sectional Survey.

Adv Med Educ Pract 2019 15;10:855-866. Epub 2019 Oct 15.

Department of Surgery, University of Cape Town, Cape Town, South Africa.

Purpose: To evaluate and compare medical student and faculty perceptions of undergraduate surgical training and compare results between South Africa and Sweden.

Patients And Methods: An electronic, online questionnaire was anonymously distributed to medical students and surgical faculty at the University of Cape Town (UCT), South Africa, and the Karolinska Institutet (KI), Sweden. The questionnaire explored the perceptions of medical students and surgical faculty regarding the current undergraduate surgical curriculum, as well as existing clinical and theoretical instructional methods.

Results: A total of 120 students (response rate of 24.4%) and 41 faculty (response rate of 74.5%) responded. Students believed they ought to receive significantly more teaching when compared to surgical faculty (=0.018). Students and faculty generally agreed that students should expect to study approximately six to 20 hrs per week outside of clinical duty. There was general agreement that "small-group tutorials" was the area students learn the most from, whereas students reported "lectures" least helpful. Registrars were reported as the first person students should consult regarding patient care. Fifty-one (42.5%) medical students believed that faculty viewed students as an inconvenience, and 42 (35.0%) students believed that faculty would rather not have students on the clinical team. The majority of faculty (68.3%) reported significantly more negative views on the current undergraduate surgical curriculum when compared to students (=0.002). UCT faculty reported giving significantly less feedback to students during their surgical rotation when compared to KI faculty (=0.043).

Conclusion: Significant differences exist between surgical faculty and medical student perceptions regarding undergraduate surgical training in developing and developed countries. In order to increase surgical interest among undergraduate medical students, it is imperative for surgical educators to be aware of these differences and find specific strategies to bridge this gap.
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http://dx.doi.org/10.2147/AMEP.S216027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800552PMC
October 2019

A New Recalibrated Four-Category Child-Pugh Score Performs Better than the Original Child-Pugh and MELD Scores in Predicting In-Hospital Mortality in Decompensated Alcoholic Cirrhotic Patients with Acute Variceal Bleeding: a Real-World Cohort Analysis.

World J Surg 2020 01;44(1):241-246

Department of Surgery, Dalhousie University, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.

Background: There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP).

Methods: This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves.

Results: During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004).

Conclusion: A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.
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http://dx.doi.org/10.1007/s00268-019-05211-8DOI Listing
January 2020

Evolution of bile duct repair in a low and middle-income country (LMIC): a comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991 to 2004 and 2005-2017.

HPB (Oxford) 2020 03 16;22(3):391-397. Epub 2019 Aug 16.

Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa.

Background: There is a paucity of data from the developing world regarding laparoscopic cholecystectomy (LC) bile duct injuries (BDIs), despite the fact that most of the world's population live in a developing country. We assessed how referral patterns, management and outcomes after LC-BDI repair have evolved over time in patients treated at a tertiary referral center in a low and middle-income country (LMIC).

Methods: Patients with LC-BDIs requiring hepaticojejunostomy were identified from a prospective database. Clinical characteristics, geographic distance from referral hospital, timing of referral and repair, and post-operative outcomes were compared in two cohorts treated during 1991-2004 and 2005-2017.

Results: Of 125 patients, 32 underwent repair in the early period, 93 in the latter. There was no difference in demographic or clinical characteristics, but a 45.6% increase in geographically distant referrals in the 2005-2017 period. Time from diagnosis to referral and referral to repair increased significantly (p = 0.031, p < 0.001), necessitating more intermediate repairs. Despite this, the number of severe complications decreased (p = 0.022) while long-term outcomes remained unchanged.

Conclusion: In this study from an LMIC, geographic and logistic constraints necessitated deviation from accepted algorithms devised for well-resourced countries. When appropriately adapted, results comparable to those reported from developed countries are achievable.
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http://dx.doi.org/10.1016/j.hpb.2019.07.009DOI Listing
March 2020

Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

Int J Surg Case Rep 2019 28;60:340-344. Epub 2019 Jun 28.

Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa. Electronic address:

Introduction: Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone.

Materials And Methods: Two patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length.

Results: In both patients the intraperitoneal PTC/ERC rendezvous with SEMS placement was successful with no complications after 12 and 18 months follow-up, respectively.

Discussion: This study is the first to report a standardized approach to the acute management of iatrogenic and non-iatrogenic major BDIs using extraluminal intraperitoneal PTC/ERC rendezvous with placement of a fully covered SEMS. The described technique may serve as a "bridge to surgery" strategy for patients where definitive management of BDIs are deferred. However, long-term data of the success of this technique, specifically the use of a SEMS to bridge the defect, are lacking and further investigation is required to determine its role as a definitive treatment of BDIs with substance loss.

Conclusion: PTC/ERC rendezvous with restoration of biliary continuity and internalization of bile flow is particularly useful for patients who have previously failed ERC and/or PTC alone, and in whom immediate surgical repair is not an option.
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http://dx.doi.org/10.1016/j.ijscr.2019.06.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6612668PMC
June 2019

An analysis of early postoperative complications following biliary reconstruction of major bile duct injuries using the Modified Accordion and Anatomic, Timing Of and Mechanism classifications.

Surg Open Sci 2019 Jul 3;1(1):2-6. Epub 2019 Mar 3.

Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa.

Background: Few studies have reported patient outcome after surgical repair of bile duct injury using a standardized, validated classification system. This is the first analysis to investigate the correlation between the Anatomic, Timing Of and Mechanism classification of bile duct injury and severity of postoperative complications classified using the Modified Accordion Grading System.

Methods: Patients undergoing index hepaticojejunostomy repair of bile duct injury in laparoscopic cholecystectomy at a tertiary referral center from 1993-2018 were included. Patient demographics, geographic distance from referral center, time to referral, Anatomic, Timing Of and Mechanism classification and highest Modified Accordion Grade complication were retrieved from a prospective database. The primary outcome was determined using correlation statistics to assess the relationship between level of injury and severity of postoperative complication.

Results: One hundred and twenty-eight patients were included. There was no correlation between level of injury and severity of postoperative complication ( (128) = -0.113, P = .203). Seventy (54.7%) patients had an injury less than 2 cm from the hepatic duct bifurcation and 52% of patients developed a postoperative complication, most mild to moderate in severity. Geographic distance resulted in substantial delays in referral (P < .001) but did not affect complication rate (P = .523).

Conclusion: In this prospective analysis the short-term complication rate was higher than previous retrospective reports, but the distribution of the severity of complications and spectrum of injury type were similar. There was no correlation between severity of injury and postoperative complications. Geographic distance from referral center resulted in substantial differences in referral delay but had no statistically significant effect on outcome.
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http://dx.doi.org/10.1016/j.sopen.2019.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391892PMC
July 2019

Recalcitrant embedded biliary self-expanding metal stents: a novel technique for endoscopic extraction.

VideoGIE 2019 Feb 8;4(2):72-75. Epub 2019 Jan 8.

Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa.

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http://dx.doi.org/10.1016/j.vgie.2018.09.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362311PMC
February 2019

Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists.

Surgery 2019 02 9;165(2):337-344. Epub 2018 Oct 9.

Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. Electronic address:

Background: Fluid and pain management during liver surgery (eg, low central venous pressure) is a classic topic of controversy between anesthesiologists and surgeons. Little is known about practices worldwide. The aim of this study was to assess perioperative practices in liver surgery among and between surgeons and anesthesiologists worldwide that could guide the design of future international studies.

Methods: An online questionnaire was sent to 22 societies, including 4 international hepatopancreatobiliary societies, the American Society of Anesthesiologists, and 17 other (inter-)national societies.

Results: A total of 913 participants (495 surgeons and 418 anesthesiologists) from 66 countries were surveyed. A large heterogeneity in fluid management practices was identified, with 66% using low central venous pressure, 22% goal-directed fluid therapy, and 6% normovolemia. In addition, large heterogeneity was found regarding pain management practices, with 49% using epidural analgesia, 25% patient-controlled analgesia with opioids, and 12% regional techniques. Most participants assume that there is a relation between perioperative pain management and morbidity and mortality (78% of surgeons vs 89% of anesthesiologists; P < .001). Both surgeons and anesthesiologists have the highest expectations for minimally invasive surgery and enhanced recovery pathways for improving outcomes in liver surgery. No clear differences between continents were found.

Conclusion: Worldwide there is a large heterogeneity in fluid and pain management practices in liver surgery. This survey identified several areas of interest for future international studies aiming to improve outcomes in liver surgery.
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http://dx.doi.org/10.1016/j.surg.2018.08.013DOI Listing
February 2019

Inversed relationship between completeness of follow-up and coverage of postoperative complications in gallstone surgery and ERCP: a potential source of bias in patient registers.

BMJ Open 2018 01 23;8(1):e019551. Epub 2018 Jan 23.

Division of Surgery, CLINTEC, KarolinskaInstitutet, Stockholm, Sweden.

Objective: To analyse the completeness in GallRiks of the follow-up frequency in relation to the intraoperative and postoperative outcome.

Design: Population-based register study.

Setting: Data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP), GallRiks.

Population: All cholecystectomies and ERCPs recorded in GallRiks between 1 January 2006 and 31 December 2014.

Main Outcome Measures: Outcomes for intraprocedural as well as postprocedural adverse events between units with either a 30-day follow-up of ≥90% compared with those with a less frequent follow-up (<90%).

Results: Between 2006 and 2014, 162 212 cholecystectomies and ERCP procedures were registered in GallRiks. After the exclusion of non-index procedures and those with incomplete data 152 827 procedures remained for final analyses. In patients having a cholecystectomy, there were no differences regarding the adverse event rates, irrespective of the follow-up frequency. However, in the more complicated endoscopic ERCP procedures, the postoperative adverse event rates were significantly higher in those with a more frequent and complete 30-day follow-up (OR 1.92; 95% CI 1.76 to 2.11).

Conclusions: Differences in the follow-up frequency in registries affect the reported outcomes as exemplified by the complicated endoscopic ERCP procedures. A high and complete follow-up rate shall serve as an additional quality indicator for surgical registries.
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http://dx.doi.org/10.1136/bmjopen-2017-019551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786088PMC
January 2018

Colorectal cancer liver metastases - a population-based study on incidence, management and survival.

BMC Cancer 2018 01 15;18(1):78. Epub 2018 Jan 15.

Division of Surgery, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, 182 88, Stockholm, Sweden.

Background: Colorectal cancer (CRC) is a leading cause of cancer-associated deaths with liver metastases developing in 25-30% of those affected. Previous data suggest a survival difference between right- and left-sided liver metastatic CRC, even though left-sided cancer has a higher incidence of liver metastases. The aim of the study was to describe the liver metastatic patterns and survival as a function of the characteristics of the primary tumour and different combinations of metastatic disease.

Methods: A retrospective population-based study was performed on a cohort of patients diagnosed with CRC in the region of Stockholm, Sweden during 2008. Patients were identified through the Swedish National Quality Registry for Colorectal Cancer Treatment (SCRCR) and additional information on intra- and extra-hepatic metastatic pattern and treatment were retrieved from electronic patient records. Patients were followed for 5 years or until death. Factors influencing overall survival (OS) were investigated by means of Cox regression. OS was compared using Kaplan-Meier estimations and the log-rank test.

Results: Liver metastases were diagnosed in 272/1026 (26.5%) patients within five years of diagnosis of the primary. Liver and lung metastases were more often diagnosed in left-sided colon cancer compared to right-sided cancer (28.4% versus 22.1%, p = 0.029 and 19.7% versus 13.2%, p = 0.010, respectively) but the extent of liver metastases were more extensive for right-sided cancer as compared to left-sided (p = 0.001). Liver metastatic left-sided cancer, including rectal cancer, was associated with a 44% decreased mortality risk compared to right-sided cancer (HR = 0.56, 95% CI: 0.39-0.79) with a 5-year OS of 16.6% versus 4.3% (p < 0.001). In liver metastatic CRC, the presence of lung metastases did not significantly influence OS as assessed by multivariate analysis (HR = 1.11, 95% CI: 0.80-1.53).

Conclusion: The worse survival in liver metastatic right-sided colon cancer could possibly be explained by the higher number of metastases, as well as more extensive segmental involvement compared with left-sided colon and rectal cancer, even though the latter had a higher incidence of liver metastases. Detailed population-based data on the metastatic pattern of CRC and survival could assist in more structured and individualized guidelines for follow-up of patients with CRC.
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http://dx.doi.org/10.1186/s12885-017-3925-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769309PMC
January 2018

High incidence of biliary stricture after associating liver partition and portal vein ligation for staged hepatectomy.

ANZ J Surg 2018 Jul-Aug;88(7-8):760-764. Epub 2017 Dec 14.

Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure most frequently applied in the setting of an extended right-sided hemi-hepatectomy. Initial reports of high mortality have sparked debate regarding the safety and efficacy of the procedure. We describe a higher incidence of early post-operative bile duct strictures after ALPPS, a complication rarely seen after conventional liver resection.

Methods: An institutional review was conducted to assess the incidence of post-operative biliary strictures following conventional right-sided or extended right-sided hemi-hepatectomy and ALPPS. Patient demographics and operative data were obtained from the patient database of Karolinska University Hospital.

Results: Between 2010 and 2015, 528 hemi-hepatectomies or extended hemi-hepatectomies were performed, of which 500 were conventional liver resections and 28 were ALPPS. The incidence of post-operative biliary stricture was 10.7% (n = 3) following ALPPS, 1.4% (n = 2) following extended right-sided hepatectomy (P = 0.023; OR = 8.46; 95% CI 1.35-53.2) and 1.1% following formal right-sided hepatectomy (P = 0.004; OR = 11.0; 95% CI 2.11-57.6). All biliary strictures were at the level of the hilum affecting the left hepatic duct. Pre-operative comorbidity was less in the ALPPS group and post-operative complications were more severe following ALPPS.

Conclusion: Iatrogenic biliary strictures following conventional liver resection is an uncommon complication. It does, however, occur more frequently following ALPPS and is associated with an increased morbidity. Caution should therefore be exercised when dividing the right hilar pedicle at stage 2 of ALPPS.
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http://dx.doi.org/10.1111/ans.14252DOI Listing
August 2019

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 16;25(1):96-100. Epub 2017 Dec 16.

Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India.

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.519DOI Listing
January 2018

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 9;25(1):3-16. Epub 2018 Jan 9.

Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina.

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.518DOI Listing
January 2018

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 20;25(1):55-72. Epub 2017 Dec 20.

Director, Mie Prefectural Ichishi Hospital, Mie, Japan.

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.516DOI Listing
January 2018

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 9;25(1):41-54. Epub 2018 Jan 9.

Mt Elizabeth Novena Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1 edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.515DOI Listing
January 2018

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 5;25(1):17-30. Epub 2018 Jan 5.

Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan.

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.512DOI Listing
January 2018

Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis.

J Hepatobiliary Pancreat Sci 2018 Jan 8;25(1):31-40. Epub 2018 Jan 8.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.509DOI Listing
January 2018

Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 21;25(1):87-95. Epub 2017 Nov 21.

Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.

Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.504DOI Listing
January 2018

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

J Hepatobiliary Pancreat Sci 2017 Nov 23;24(11):591-602. Epub 2017 Oct 23.

Surgical Gastroenterology/Hepatopancreatobiliary Unit, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.
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http://dx.doi.org/10.1002/jhbp.503DOI Listing
November 2017

The Impact of a Hepatobiliary Multidisciplinary Team Assessment in Patients with Colorectal Cancer Liver Metastases: A Population-Based Study.

Oncologist 2017 09 26;22(9):1067-1074. Epub 2017 May 26.

Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden.

Background: Assessing patients with colorectal cancer liver metastases (CRCLM) by a liver multidisciplinary team (MDT) results in higher resection rates and improved survival. The aim of this study was to evaluate the potentially improved resection rate in a defined cohort if all patients with CRCLM were evaluated by a liver MDT.

Patients And Methods: A retrospective analysis of patients diagnosed with colorectal cancer during 2008 in the greater Stockholm region was conducted. All patients with liver metastases (LM), detected during 5-year follow-up, were re-evaluated at a fictive liver MDT in which previous imaging studies, tumor characteristics, medical history, and patients' own treatment preferences were presented. Treatment decisions for each patient were compared to the original management. Odds ratios (ORs) and 95% confidence intervals were estimated for factors associated with referral to the liver MDT.

Results: Of 272 patients diagnosed with LM, 102 patients were discussed at an original liver MDT and 69 patients were eventually resected. At the fictive liver MDT, a further 22 patients were considered as resectable/potentially resectable, none previously assessed by a hepatobiliary surgeon. Factors influencing referral to liver MDT were age (OR 3.12, 1.72-5.65), American Society of Anaesthesiologists (ASA) score (OR 0.34, 0.18-0.63; ASA 2 vs. ASA 3), and number of LM (OR 0.10, 0.04-0.22; 1-5 LM vs. >10 LM), while gender ( = .194) and treatment at a teaching hospital ( = .838) were not.

Conclusion: A meaningful number of patients with liver metastases are not managed according to best available evidence and the potential for higher resection rates is substantial.

Implications For Practice: Patients with liver metastatic colorectal cancer who are assessed at a hepatobiliary multidisciplinary meeting achieve higher resection rates and improved survival. Unfortunately, patients who may benefit from resection are not always properly referred. In this study, the potential improved resection rate was assessed by re-evaluating all patients with liver metastases from a population-based cohort, including patients with extrahepatic metastases and accounting for comorbidity and patients' own preferences towards treatment. An additional 12.9% of the patients were found to be potentially resectable. The results highlight the importance of all patients being evaluated in the setting of a hepatobiliary multidisciplinary meeting.
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http://dx.doi.org/10.1634/theoncologist.2017-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599196PMC
September 2017
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