An end of an era
This December issue of HPB brings to a close a wonderful association with our publisher, Wiley Blackwell. As Editor‐in‐Chief of the journal, my editorial team and I have been well supported since 2009 by Wiley Blackwell staff who have been based at various times in their offices in Edinburgh, Chichester, Oxford and Singapore. They have helped greatly in ensuring that the journal has achieved such high standing in the surgical community during my period of office. With them, we delivered a new look for HPB, secured indexing of the Journal by the National Library of Medicine and delivered on my mission to secure an impact factor for the Journal of 2 in the first five years. I am grateful to all the staff who have worked with the editorial team over the last seven years. We look forward to working with our new publishers, Elsevier, who will liaise closely with Wiley Blackwell to ensure a smooth transition of publisher.
This issue sees our first, but hopefully not last, laboratory based work around the associating liver partition and portal vein ligation procedure (ALPPS). Croome and colleagues from the Mayo Clinic have delivered a welcome animal model, which will hopefully help us to understand the precise role of the ALPPS procedure. There has been much clinical anecdote presented in the past but these workers seem to have struck upon a reproducible model that will allow investigators to identify factors that might influence liver hypertrophy and the selection of patients for this still controversial procedure. An end of an era indeed!
Predicting liver failure and death after hepatectomy
There have been many attempts to define predictive models for the identification of patients at risk of posthepatectomy liver failure (PHLF) and death. These have previously been hindered by the lack of a robust definition of PHLF and the two most commonly used definitions – the 50‐50 and International Study Group of Liver Surgery (ISGLS) criteria – have now helped with this. These definitions are based on a coagulation parameter (prothrombin time) and the serum bilirubin, reflecting the synthetic and excretory/detoxifying functions of the liver. One criticism of these is that the criteria are taken on day 5 after surgery; a time‐point some have argued is too late.
In this issue of HPB,Herbert and colleagues present an analysis of 1528 major hepatectomy patients and examine the dynamics of serum phosphate and creatinine in the immediate post‐op period. It was previously shown in this journal that a failure of phosphate levels to fall after surgery was associated with liver failure and death (Squires, HPB, 2014). Low serum phosphate after liver resection is well recognised and originally thought to be a consequence of consumption during liver hypertrophy. However, while active take‐up of phosphate into the liver after hepatectomy does happen, this is insufficient to fully explain hypophosphataemia. The authors point to studies demonstrating a significant increase in the urinary excretion of phosphate following hepatectomy which may also contribute.
Herbert and colleagues provide a practical definition: creatinine on day 1 post surgery (PoD1) > day of surgery (DoS) and phosphate fails to decrease by 20% from DoS to PoD1. There is a strong association in multivariable analyses with death (Odds ratio 2.53, 1.36–4.71) and PHLF (3.89, 1.85–8.37).
The serum phosphate/creatinine definition identified 52% of those that died, but also 25% that survived without evidence of PHLF. It may be that this can be improved by incorporating other parameters, or my identifying a high risk group a priori. Given the lack of specific therapies beyond that of high quality intensive care, whether death can actually be averted is separate question.
Impact of vascular resection in the surgical management of hepatobiliary malignancy – how far should we go?
As we observe improved responses to multi‐modality therapy for hepatobiliary and pancreatic malignancies and surgical intervention becomes safer, increasingly radical resections are being performed with curative intent. In this issue of HPB, Shen and colleagues add to the growing body of literature exploring the impact of hepatic and vascular resection on peri‐operative morbidity and mortality in patients undergoing surgical resection for hepatobiliary malignancy. The authors utilize the NSQIP database to evaluate a large cohort of patients that has undergone biliary enteric anastomosis concomitant with hepatic resection in isolation, or in combination with vascular resection for the treatment of a variety of hepatobiliary malignancies. Though there are limitations to the study with respect to identifying a pure population of patients with a single underlying diagnosis, the majority of patients represented in this study have hilar cholangiocarcinoma and the study lends insight into the additional morbidity and mortality assumed with more radical resection for these advanced tumors. Patients suffered a 30 day mortality rate of 19% in the present study when undergoing concomitant vascular resection and reconstruction. This population based analysis likely reflects a truer reality of the outcomes these patients experience than the more frequently reported single institution series which usually reflect the outcomes of a highly selected group of patients and procedures performed by skilled high volume surgeons. The small number of patients available for analysis in the subset of patients undergoing vascular reconstruction (n = 42) in this very large national quality collaborative database also emphasizes the prohibitive challenges of evaluating these more aggressive surgical approaches in the context of a randomized trial. In the end as thoughtful surgeons we should continue to push surgical boundaries but must carefully evaluate our outcomes prospectively. Surgical resection will likely always play a role in the management of these difficult tumors, but we are wise to remember the advice of Dr. Blake Cady, ‘Biology is king. Selection is queen. Technical maneuvers are the prince and princess. Occasionally the prince or princess tries to usurp the throne; they almost always fail to overthrow the forces of the king and queen.’
© 2015 International Hepato-Pancreato-Biliary Association. Published by Elsevier Inc.
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