Reach for the endoscope or the wire but not the knife for biliary stricture after living donor liver transplantation

Here is my highlight from the April issue of HPB. This focuses on an excellent paper describing non-operative intervention for biliary stricture complicating living donor liver transplantation.

  1. Gun Hyung Na,
  2. Dong Goo Kim*,
  3. Ho Joong Choi,
  4. Jae Hyun Han,
  5. Tae Ho Hong and
  6. Young Kyoung You

 

Re-operating on patients after liver transplantation is never a rewarding experience and can be extremely dangerous. When a patient has undergone a living donor liver transplant (LDLT) the stakes are even higher as there may be no opportunity for deceased donor rescue in case of vascular complications. Biliary stricture is common after living donor liver transplant and can be difficult to manage. Many LDLT programmes are small and do not have the case experience to manage such complications with complete confidence. It is really important therefore to learn from centres like St Mary’s Hospital, Seoul, Korea who have a vast experience. In this edition of HPB this centre reports its approach to managing 160 biliary strictures occurring in almost 500 patients who received a right lobe LDLT with a duct to duct anastomosis. The greatest single risk for development of biliary stricture was a post transplant bile leak and urgent surgery was also associated with greater risk. The authors have shown that using a variety of techniques such as ERCP, PTBD or combinations of these procedures it is possible to manage almost all such strictures. The avoidance of major revisional surgery is undoubtedly to the advantage of these patients. The number of failures was remarkably small but sepsis combined with biliary stricture was associated with a small number of deaths. The value of these interventional approaches is shown by the observation that overall survival was not significantly different between patients with and without a biliary stricture and in both cases this exceeded 80% at 5 years.

Image

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Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure

Here is my highlight from the February edition of the journal HPB the official journal of the IHPBA

The legend of Prometheus that first documented the extraordinary capacity of the liver to regenerate is familiar to liver surgeons. Major liver resection relies on this regenerative capacity of the liver to restore volume and function after surgery. Acetominophen toxicity (paracetomol) causes widespread hepatocyte necrosis but we know from animal models and human survivors that complete hepatic regeneration is possible. The time to allow liver regeneration is unfortunately too slow for many patients who will either die or require urgent liver transplantation to avoid the consequences of severe acute liver failure. In this edition of HPB, the Leeds group present a series of patients who have been managed in an extraordinary way. These patients who all had acute liver failure and who met criteria for urgent transplantation (which equates to a near 90% mortality without transplantation),underwent a right trisegmentectomy, preserving segments 1,2 & 3 and then underwent a reduced or split graft right lobe auxiliary liver transplant. After recovering from the procedure a HIDA scan was performed to test regeneration and function in the native remnant liver and then immunosuppression was gradually withdrawn over a 6–12 month period resulting in atrophy of the transplanted liver and compensatory hypertrophy of the native liver. This innovative approach to liver transplantation has allowed a resurrection of what by many would be considered an irretrievably damaged liver. The avoidance of the need for long term immunosuppression in what is usually a young population may contribute in part to the better 5 year survival in patients. This is however, a technical tour de force and it will be interesting to see if other centres are persuaded to give it a go.

Prometheus

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Bidloo’s liver: the story behind the story

We recently wrote an essay called Govert Bidloo’s liver; human symmetry reflected.” The story behind this essay is quite unusual and interesting. I thought I would just tell the story behind the story for interest without repeating the whole thing but there is a link to the article at the bottom of this blog.

Bidloo first came into my consciousness  when one of our research fellows in Edinburgh, Rachel Guest, sent around an email encouraging a few of our research group to have a look at an item made public by the Vassar College library in New York. The Vassar library has a great reputation and to mark the one millionth acquisition  to their collection they decided to purchase a very special book. The book that they chose was one of a few existing copies of an anatomical atlas created by the Dutch anatomist Govert Bidloo. The atlas, which is titled Anatomia humana corporis, was published in 1685 and is particularly famous because of the quality of the imagery indeed it was the first anatomical atlas to use the novel (for the time) high resolution copperplate printing technique. Due to the significance of this book in their collection, Vassar made the book available on the internet, the first time it was accessible to the general public in this way. As I flicked through the pages and being a liver specialist, I was looking for a plate that showed a representation of the liver. When I found it  (plate 37) I can remember looking at the image with absolute horror. The cause of my alarm was that the liver was the wrong way around! If you had only ever seen a right hand drive car it was the equivalent to seeing a car with the steering wheel on the opposite side, such an obvious anomaly. I immediately assumed that it had been noted previously but some preliminary researches showed that this did not appear to be the case other than a small footnote by William Cowper of whom more later. I made the rest of the group aware and we considered the explanation? Could the liver have been drawn the wrong way around? Could it have been that the cadaver on whom the illustration was based had situs inversus where there is a complete transposition of organs from left to right in the abdominal cavity? This is an extraordinarily rare condition and was therefore extremely unlikely. It then occurred to us that the most likely explanation was a printing error. In copperplate printing an illustration in the correct orientation has to be copied in reverse or mirror image on to a plate so that when it is printed the image is in the correct orientation.

Rachel went to work investigating and discovered that the BIU Sante’ institute in Paris actually had images of all of the original drawings made by the artist Gerard de Lairesse from which the copperplates had been made. We were then able to compare the original drawings with the plates to check for orientation. We looked through the atlas and actually found other plates, apart from the liver, where the image was reversed but in most of these reversal of the image did not change it’s meaning, since much of human anatomy is symmetrical. The liver of course is an exception. We then realised that the atlas had been famously plagiarised with an English version written by William Cowper which added drama and intrigue to the story.

To verify our assumptions and investigations we really needed an expert to comment on the historical accuracy of our observations. We particularly needed someone with expertise in the Dutch Golden Age, anatomical illustrations and printing techniques of the time. This seemed a very tall order, however, we found one such expert, Daniel Margocsy, who lectures in history in Hunter College New York. After an email approach, Daniel expressed his interest, corrected us on some points and embellished others and added colour and richness to our understanding of the period. Rachel crafted a beautiful manuscript which we tweaked and adjusted until we were all happy and then, more in hope than expectation, we submitted it to the Lancet for publication. After a long delay we all assumed that the manuscript had been consigned to recycling however a probing email revealed quite the opposite and the journal were prepared to publish the article. You can read it here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60248-8/fulltext

bidloo copy

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Liver transplantation for cholangiocarcinoma- a hammer to crack a very tough nut?

I am woefully behind in posting new material on my blog for which I apologise. Everyone else’s deadlines seem to have taken over mine. Nevertheless it is a new year and I will resolve to spend more time and effort posting here.

Here is my highlight from the january edition of the journal HPB on quite a controversial area.

This month’s HPB sees the much awaited publication of the Dublin experience of liver transplantation for cholangiocarcinoma. The group followed the previously published Mayo protocol of treating patients with cholangiocarcinoma with brachytherapy, external beam radiotherapy and 5-fluorouracil. Patients who had no radiological evidence of disease progression underwent laparotomy or laparoscopy and negative lymph node biopsy and ifthere was no evidence of peritoneal dissemination were listed for transplantation. 27 patients entered the protocol and 20 progressed to transplantation, 6 of whom required a simultaneous pancreaticoduodenectomy. Hospital mortality was 4/20 or 20% but thereafter survival was reasonable giving overall survival estimates of approximately 75% at 1 year and 60% at 3 years. Liver transplantation for cholangiocarcinoma is a major undertaking but in oncological terms the results are very good. The present series found best outcomes in patients with a complete pathological response to neoadjuvant therapy although it could be argued that such patients may have experienced prolonged survival without transplantation. The authors highlight the difficulty in determining the presence or absence of viable tumour in the liver after chemoradiotherapy. The Dublin series did not replicate the excellent results previously published in similarly selected patients from the Mayo Clinic, however, there is increasing interest in the use of liver transplantation for primary and metastatic disease including cholangiocarcinoma, neuroendocrine and colorectal metastases. The availability of organs for transplantation remains a limiting factor but carefully designed studies such as this, strengthen the case for extending indications for liver transplantation at least within the context of a clinical trial.

Neoadjuvant chemoradiotherapy followed by liver transplantation for unresectable cholangiocarcinoma: a single-centre national experience (pages 91–98)

Sophie Duignan, Donal Maguire, Chamarajanagar S. Ravichand, Justin Geoghegan, Emir Hoti, David Fennelly, John Armstrong, Kathy Rock, Helen Mohan and Oscar Traynor

Article first published online: 18 APR 2013 | DOI: 10.1111/hpb.12082

 

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Liver metastases through a glass less darkly

Here is my latest highlight from the journal HPB December issue.

Achieving R0 resection margins is the best way to cure colorectal liver metastases but patterns of recurrence within the liver suggest that some lesions are missed by pre-operative imaging or intraoperative ultrasound (IOUSS). Peloso and colleagues in this edition of HPB, describe a pilot study using the autofluorescent qualities of indocyanine green (ICG) to increase the sensitivity of intraoperative detection of occult liver metastases. They took a cohort of 25 patients who had undergone pre-operative CT and administered a bolus of ICG the day before liver resection. At laparotomy, they used a near infrared camera to look for ICG-related fluorescence and detected a number of occult metastases that were not seen on either pre-operative CT or IOUSS. This study is interesting as it reports an improvement of detection in lesions that might currently be missed. There are a number of limitations not least that CT was the comparative mode of cross-sectional imaging used in this study whereas many centres use magnetic resonance imaging and fluorodeoxyglucose positron emission tomography as a routine part of the pre-operative work up for colorectal metastases. New imaging innovations must be compared with current gold standards to gain credibility. ICG is excreted by hepatocytes through the biliary system and can accumulate in the gall bladder and bile ducts. It would be interesting to know whether this creates a strong signal around the gall bladder which might potentially mask metastases in this area. ICG has potential as an adjunct to intraoperative imaging in liver surgery and it will be interesting to see how this story unfolds.Slide1

Combined use of intraoperative ultrasound and indocyanine green fluorescence imaging to detect liver metastases from colorectal cancer (pages 928–934)

Andrea Peloso, Eloisa Franchi, Maria C. Canepa, Letizia Barbieri, Laura Briani, Jacopo Ferrario, Carolina Bianco, Pietro Quaretti, Silvia Brugnatelli, Paolo Dionigi and Marcello Maestri HPB December 2013

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The case of the vanishing yellow man

I recently gave a public lecture as part of the University of Edinburgh Medical Detectives lecture series. This is a series of public talks based loosely on the fact that Sir Arthur Conan Doyle, a former medical student in Edinburgh created the character of Sherlock Holmes who pieced together fragments of information and observation to reach a conclusion and that much of medical research follows a similar course. “The case of the vanishing yellow man” is my take on research on liver failure drawing on acute settings and chronic liver disease and looking forward to how transplantation and cell technology may provide new avenues for treating cirrhosis in the future. The talk has been edited down to just under 40 minutes.

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Practical information for Online Surgery Masters courses in Edinburgh

The Edinburgh Surgery group have developed a number of distance learning courses in surgery through the initiative of Professor James Garden.  Applications for this academic year are now closed but if you are considering applying for next year this article will provide some useful information.

The most established online distance learning course is the award winning Masters in Surgical Sciences (MSc)-  Edinburgh Surgical Science Qualification (ESSQ) run jointly by the University of Edinburgh and the Royal College of Surgeons of Edinburgh . We have been delighted to  see first-hand the positive effects of this programme on trainees approaching the MRCS exam.

With the Edinburgh Specialist Surgical Qualification, ChM in General Surgery, having launched 2 years ago and graduating its first students this year and the ChM in Trauma and Orthopaedics as well as the ChM in Urology launching last September, we are now starting to see evidence of how advanced trainees can also benefit from this type of course. This year has seen the launch of a new ChM in Vascular and Endovascular surgery, with two excellent year directors David Lewis and Andrew Tambyraja.

Rather than tell you about these programmes from a programme director’s point of view, I thought it would be more interesting to ask the eFacilitators of the distance learning surgical programmes, who are employed full time to ensure the smooth running of these programmes, to address some of the most common questions that prospective students have. Dr Paula Smith facilitates the ESSQ MSc as well as the ChM in Urology. Dr David Pier facilitates the ChM in General Surgery and the ChM in Trauma and Orthopaedics. Paula and David interact with the students on a day to day basis.

Can you give a brief description of the MSc in surgical sciences course?

  Paula Smith  “The course is designed for surgical trainees who are looking to advance their knowledgebase and prepare for the MRCS examination whilst gaining a postgraduate qualification.

The MSc is a 3 year part-time course that is designed to give a firm grounding in basic sciences as they relate to surgery in Certificate year whilst focusing on pre- per- and postoperative care, principles of surgical management and surgical skills in the Diploma year. In the second year the course provides core academic skills that are then developed in the final Masters year through the production of a research dissertation. The research has been of a fantastic standard with over 18 peer reviewed journal publications resulting from this work in recent years.”

 Thanks Paula. Having read a large number of these final year dissertations I agree completely and look forward to seeing further research output from past students.

How does the ChM programme differ from that of the masters?

  David Pier “The ChM courses have built upon our experience with the MSc and developed a programme that prepares the advanced trainee for the Fellowship of the Royal College of Surgeons exit examination.

In the later years of surgical training, the on-going academic development of the trainee has been delivered traditionally during a period of clinical or laboratory research training.  No matter how highly an MD or PhD thesis is regarded, taking two to three years out of surgical training may not sit well with the trainees desire to progress seamlessly and in a short time to a high level of competence in surgical practice. The ChM programmes are designed to fit alongside surgical training and use a similar format as ESSQ, of supportive distance learning but delivered towards the end of surgical training. The content of the course is aligned with the Intercollegiate Surgical Curriculum Programme (ISCP) to best prepare the student for the FRCS exam.”

 All of the ESSQ programmes are run as collaborations between the University of Edinburgh and The Royal College of Surgeons of Edinburgh, how does this benefit the programmes?

 Paula Smith “Edinburgh is in a prime position to host partnership postgraduate programmes in Surgery. The Royal College of Surgeons of Edinburgh is dedicated to the maintenance and promotion of the highest standards of surgical practice, through its keen interest in education, training and rigorous examination and through its liaison with external medical bodies. The RCSEd celebrated its Quincentenary in 2005 yet prides itself also on its innovation and adaptability. The RCSEd led the introduction of the specialist exit Fellowship examination which is now delivered on an intercollegiate basis.”

 David Pier “The quality of surgical training and the academic standing of the surgical groups in Edinburgh are highly regarded. Clinical Surgery (headed by Professor O James Garden), within the Division of Health Sciences (CSCH) in the College of Medicine and Veterinary Medicine, has a national and international profile in surgical research, contributing to a 5* rating in the last RAE. The surgical group currently hold five clinician scientist intermediate research fellowships at lectureship and senior lectureship level and have strong interdisciplinary links with research.”

 Both the MSc and the three ChM programmes are linked to UK examinations. Is the course relevant to international students?

 David Pier “Actually the association between the programmes and the curricula of the Intercollegiate Fellowship Examination in Great Britain and Ireland make these courses very attractive to the international market. The knowledge and skills developed during the programmes can be directly transferred to many other international examinations. Indeed, the Royal Australasian College of Surgeons has already expressed a desire to promote the ESSQ distance learning programmes and to make specific recommendation to trainees in Australasia that these be used as a means of better preparing for its professional examination.

Also with the courses being delivered entirely online we are able to charge the same fees to all applicants no matter where they reside.

 How does the course fit with the life of a busy surgical trainee?

 Paula Smith “The course is part-time and fully online allowing students to dip in and out as their clinical activities dictate. In fact the whole course has been designed to be flexible and fit with the trainee surgeons day-to-day workload. Although we advise that the course will require 10-15hrs of input a week some students find that they are able to give the course more time if they have a quiet period at work. Equally the nature of the course means that it is easy to compensate for a week where access to the course was limited by work or personal commitments.”

 David Pier “The online nature of the course and the accessibility that this brings really helps students make the most of their downtime. Students are able to access all of the course material, ejournals and etextbooks from any computer with an internet connection anywhere in the world. In fact more and more students are visiting the course from their smartphones to make use time that may otherwise feel unproductive such as the daily commute.”

 Paula Smith “The online programmes have been so successful that the MSc in Surgical Sciences has received an National eLearning gold award for Best Distance Learning Programme – Education.”

 You mentioned discussion boards. How are these used in the course?

 Paula Smith “Both the MSc and the ChM programmes use asynchronous discussion boards as tools to deliver and assess learning objectives. In the first year of the MSc students are introduced to key topics using an interactive case scenario. Each stage of the case scenario is linked to quality assured reference material and a defined set of learning outcomes that the student can chart as they go. Once this material has been evaluated the student is invited to discuss the material with experienced tutors and evaluate their knowledge against multiple choice questions. The discussions take place asynchronously so timezone differences are not an issue.”

 David Pier “The MSc programme tends to focus on short 2 week discussion boards that follow on from one another whereas the ChM programmes utilise longer discussions that run in parallel with one another. The different styles were developed in order to allow the MSc to cover a broad range of topics whist the ChM programmes discuss complex surgical cases that develop over time.”

 Paula Smith “Feedback from students has been overwhelmingly in favour of the discussion boards. Many students highlight how informative the tutor and peer feedback can be and how it gives a more thorough understanding of topics than simply reading from a textbook.”

 What other assessments will the student complete?

 Paula Smith “On the MSc course students will also complete MCQ questions to test their learning and as a formal exam, complete mini-essays in the Diploma year and an eDissertation in the final Masters year. Past students have said that the programme and the exam have played an important part in their preparation for the MRCS exam. We are proud to say that ESSQ students score an average of 17% higher in the MRCS exam than non-ESSQ students.”

 David Pier “The ChM programmes also have in-course formative MCQ questions as well as an MCQ exam designed to mimic the FRCS experience. The programmes also have an eDissertation and a Reflect ePortfolio assignment designed to encourage critical evaluation and evidence based-practise.”

 Can you give me an idea of the average trainee that applies for the programme?

 Paula Smith “Initially we thought that the MSc would be most applicable to those trainees approaching ST3, but we are now finding that many of our students apply directly from the final year of their undergraduate course. Many applicants have already made the decision to become a surgeon from an early stage and so the course allows them to keep their surgical knowledge up to date whilst they are on rotation in a non-surgical post.”

 David Pier “Applicants for the ChM programmes are typically trainees who are looking for an alternative to an MD or PhD that does not require them to interrupt their clinical training. There are also those that are interested in the programme as a means of supporting their study towards the intercollegiate fellowship examination so they tend to have more experience and be towards the end of their training.”

 So how does a student apply?

 Paula Smith “To get more information and to find out how to apply the best thing to do is visit our marketing websites that have all the information a prospective student should need:

MSc in Surgical Sciences                                 http://www.essq.rcsed.ac.uk

ChM in General Surgery                                 http://www.chm.rcsed.ac.uk

ChM in Urology                                                http://www.urochm.rcsed.ac.uk

ChM in Trauma & Orthopaedics                   http://www.orthochm.rcsed.ac.uk

 David Pier For any other queries we have dedicated email addresses

MSc Programme                                                    essqinfo@rcsed.ac.uk

ChM Programmes                                                 chminfo@rcsed.ac.uk

Applications are now closed for 2013 but you can register interest at any time for next year’s programmes. 

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