Within the largest multi-institutional analysis of 30-day outcomes after hepaticojejunostomies for BDI in the US, morbidity and mortality rates were established at 26.3% and 2% respectively. ASA class and preoperative functional status remain the main risk factors for surgery. Earlier repair in the face of ongoing sepsis and disability is associated with worse outcomes. A multidisciplinary approach at a specialized center aimed at controlling infection and improving functional status prior to surgical reconstruction is recommended.

The absolute volume of FLR required to avoid postoperative liver insufficiency is dependent on the patient, disease, and anatomic factors. Rapid expansion of the FLR can be achieved with PVE of contralateral liver segments. Although multiple metrics have been used to correlate hypertrophy with postoperative outcomes after PVE, the kinetic growth rate (KGR) is the most reliable predictor of freedom from postoperative liver insufficiency. PVE is now considered a safe and effective procedure when performed at high-volume hepatobiliary centers. It is an effective tool that, by lowering the risk of liver failure, increases the number of patients who can undergo potential curative hepatectomy.

Background The incidence of venous thromboembolism remains high after liver surgery. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis in liver surgery for the prevention of venous thromboembolism (VTE). Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included Thrombo-Embolic Deterrent hose and sequential compression devices. Once hemostasis was assured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive (MIS) hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) MIS approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1% and 10.5% respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and POD 1 for 84 (67.7%) patients. During 90-days of follow-up, no postoperative symptomatic DVT or pulmonary embolic events were diagnosed. Standard protocol computed tomography scans of the chest/abdomen/pelvis that were obtained on 112 (90.3%) study patients identified no pulmonary emboli, other thoracic, splanchnic, or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.

Background: Pathways of Enhanced Recovery in Liver Surgery (ERILS) decrease inpatient opioid use, however, there is little existing data regarding their effect on discharge prescriptions and post-discharge opioid intake. Methods: For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to ERILS and traditional pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The ERILS protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. Results: Of 244 cases, 147 ERILS patients were compared to 97 traditional pathway patients. ERILS patients were older (median 57 vs. 52 years, p=0.031) and more frequently had minimally invasive operations (37% vs. 16%, p<0.001), with fewer major complications (2% vs. 9%, p=0.011). ERILS patients were less likely to be discharged with a prescription for traditional opioids (26% vs. 79%, p<0.001) and less likely to require opioids at their first postoperative visit (19% vs. 61%, p<0.001) despite similarly low, patient-reported pain scores (median 2/10 both groups, p=0.500). On multivariable analysis, traditional recovery pathway were associated with traditional opioid use at first follow-up (OR 6.4, 95% CI 3.5-12.1; p<0.001). Conclusions: The implementation of an ERILS pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other

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Background: With the increasing use of biliary stents for neoadjuvant therapy (NT) for pancreatic adenocarcinoma (PDAC), the risk of post-pancreaticoduodenectomy (PD) infection remains relevant. This study documents the contemporary incidence of stent-related complications (SRC) during NT and to analyze their impact on surgical infections. Methods: Consecutive patients from a single institution (2011-15) with resected PDAC treated with biliary decompression, NT, and PD were analyzed. Stent-related complications (SRC) were compared among patients with/without prospectively documented composite pre-and post-operative infections (surgical site infection [SSI], organ space infection [OSI], and cholangitis). Results: Of 114 total patients, (median 164 days, initial stent to surgery), 95% had initial endoscopic (vs. percutaneous) stenting. Initial stents were often plastic (80/114, 70%), with 43/114 (38%) undergoing routine exchange to metal stent before NT. Fifteen (13%) patients had stent cholangitis during NT requiring antibiotics and/or stent exchange. There were 33/114 (29%) patients with SRC, requiring 66 exchanges. Post-PD rates of SSI, OSI, and cholangitis were 23%, 5%, and 4%, respectively [composite rate 30%]. On multivariate analysis, SRC were not associated with composite surgical infections (p > 0.05).Conclusions: Although SRC occurred in almost one-third of PDAC patients during NT, with appropriate intervention, there was no association with increased surgical infections.

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