Dr Verity Emmans
Verity Emmans has been at the helm of HPB as Journal Publishing Manager for Wiley-Blackwell over the past three years. She has done a quite outstanding job in taking our Journal to great heights and the editorial team could not have had a better colleague at a professional and personal level. I know that many Association members who have been in contact with her over the years will be sad not to have the opportunity to bid her farewell as she moves upwards within Wiley-Blackwell to a new position launching a program of Open Access Journals. We wish Verity every success for the future.
James Garden
Laparoscopic cholecystectomy in cirrhosis – select the patients well
In patients with underlying cirrhosis there is an increased incidence of cholelithiasis and consideration for cholecystectomy for complicated or symptomatic biliary disease in this group is not uncommon. Cholecystectomy in the presence of cirrhosis should be approached with caution and only by those conscious of the importance of the extent of hepatic dysfunction and portal hypertension which can result in potential complication. The aim of this well conducted systematic review by Laurence et al. was to elucidate whether a laparoscopic approach to cholecystectomy (LC) offers signifi cant benefi t to an open approach (OC) in this subgroup of patients. The authors rightly acknowledge that the quality of the data available and the conclusions that can be made from them are somewhat limited. Of the 2005 patients identifi ed for inclusion in this study, only 249 (12%) underwent OC. Only 3 randomized controlled trials (RCT) were identifi ed and they contributed only 220 (11%) of the total patients studied. Nonetheless, several important issues are highlighted from this analysis. Firstly, the mortality from the published data was 0.7% in the LC group and 2% in the OC group, with all the mortality in the OC group coming from one study. When the RCTs were analysed by meta-analytical techniques a reduction in length of stay and incidence of post operative complications but not hepatic insuffi ciency was observed in those who underwent LC. However, perhaps the key observation is that these fi ndings apply only to patients with Childs status A or B as within the whole cohort there were only 26 patients who were Childs C and 4 of them died. It would seem that the most important factor in reducing mortality associated with cholecystectomy in the presence of cirrhosis is patient selection.
Saxon Connor
Fernández-Cruz et al., p. 171
Steatosis and predicting future liver remant function in liver resection
Predicting outcomes from liver surgery is useful in establishing risk of harm, giving informed consent to the patient and anticipating the need for either pre-operative volume enhancement or post-operative supportive care. Estimation of the quality of the liver remnant has always been a diffi cult and at times subjective art. We have become accomplished and accurate at measuring and predicting the size or volume of the future liver remnant and this is useful in predicting outcome in patients with completely normal liver function. Where this falls down, however, is where the background liver is not entirely normal. Fat infi ltration of the liver is a common consequence of obesity and chemotherapy. Measurement of fat has become relatively straightforward by harnessing the capability of MRI and using specifi c protocols as described by Young and colleagues. They demonstrated that liver steatosis varied between 4 and 18% in their patients but did not add to the predictive value of future liver volume in terms of assessing outcome from liver surgery. If the assumptions are made that fat offers no value in liver synthetic or detoxifying functions but does add volume to the liver then we assume that we have to make allowance for the presence of fat and leave a larger liver volume. This relationship between fat and function is not yet that clear and further work is required. MRI measurement of steatosis may yet become an important part of risk assessment and planning in liver surgery but its association to function needs to be better defi ned.
Stephen J Wigmore
Young et al., p. 194
Discharge Disposition after Pancreatectomy
While mortality rates for pancreatic resection have fallen worldwide, morbidity rates remain high. This is especially true for older patients with associated comorbidities who undergo resection. In the USA, high morbidity rates must be managed against expectations of limiting lengths of acute care hospital stays. Is this possible? Shah et al. have analyzed USA national trends in discharge disposition following pancreatic resection for cancer and have evaluated key factors infl uencing discharge disposition. They mined a national database to identify 43,603 such patients across 1993–2005 during which mortality rates for resections decreased from 7.1% to 5.2%. Over this period, fewer and fewer patients went directly home without assistance after operation (74% in 1993 vs. 53% in 2005). Instead, more patients were discharged to another care facility (5.5% in 1993 vs. 13.3% in 2005) or discharged with specialty home health care (20% in 1993 vs. 33% in 2005). Despite 66% of patients having initial lengths of stay >10 days, ultimately only 54% of patients in 2005 had recovered suffi ciently to be discharged home without assistance. This was least likely for patients >70 yrs of age and with over 3 signifi cant comorbidities. The authors did not evaluate readmission rates. This study provides practical and useful information that can help us manage expectations and stratify risks for patients requiring pancreatectomy for cancer.
Mark Callery
Boonyanugomol et al., p. 177