Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications. (Current Controlled Trials number, ISRCTN31939699.)

ObjectiveTo perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes. Summary Background DataHospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account. MethodsIn part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death. ResultsBetween the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications.The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year. ConclusionsThe overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the singlecenter outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.In the past, pancreaticoduodenectomy has been associated with a high rate of complications (40 -60%) and a high death rate (up to 20%). Combined with a dismal prognosis, in particular for patients with pancreatic carcinoma, this led to a nihilistic approach by some clinicians.1 In experienced centers, death rates have decreased dramatically, 2-6 which has encouraged other surgeons to perform pancreatic resections in nonspecialized units. The complication and death rates of surgery depend on many variables, including the presence of malignancy, the severity of jaundice, nutritional status, infection, and impaired renal function. 7,8 These factors have allowed better patient selection. In parallel, several reports since 1995 have highlighted the influence of hospital volume on hospital death.

PurposeThis is a review of literature on the indications, technique, and outcome of portal vein embolization (PVE).MethodsA systematic literature search on outcome of PVE from 1990 to 2011 was performed in Medline, Cochrane, and Embase databases.ResultsForty-four articles were selected, including 1,791 patients with a mean age of 61 ± 4.1 years. Overall technical success rate was 99.3 %. The mean hypertrophy rate of the FRL after PVE was 37.9 ± 0.1 %. In 70 patients (3.9 %), surgery was not performed because of failure of PVE (clinical success rate 96.1 %). In 51 patients (2.8 %), the hypertrophy response was insufficient to perform liver resection. In the other 17 cases, 12 did not technically succeed (0.7 %) and 7 caused a complication leading to unresectability (0.4 %). In 6.1 %, resection was cancelled because of local tumor progression after PVE. Major complications were seen in 2.5 %, and the mortality rate was 0.1 %. A head-to-head comparison shows a negative effect of liver cirrhosis on hypertrophy response. The use of n-butyl cyanoacrylate seems to have a greater effect on hypertrophy, but the difference with other embolization materials did not reach statistical significance. No difference in regeneration is seen in patients with cholestasis or chemotherapy.ConclusionsPreoperative PVE has a high technical and clinical success rate. Liver cirrhosis has a negative effect on regeneration, but cholestasis and chemotherapy do not seem to have an influence on the hypertrophy response. The use of n-butyl cyanoacrylate may result in a greater hypertrophy response compared with other embolization materials used.

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There are large differences in prognosis after acute mesenteric ischaemia depending on aetiology. Surgical treatment of arterial embolism has improved outcome whereas the mortality rate following surgery for arterial thrombosis and non-occlusive ischaemia remains poor.

In contrast to US and CT, T1-weighted MR imaging and (1)H MR spectroscopy strongly correlate with histopathologic steatosis assessment and are able to demonstrate differences across steatosis grades. T1-weighted dual-echo MR imaging and (1)H MR spectroscopy had the best diagnostic accuracy in depicting hepatic steatosis.

Hepatic steatosis is a major factor determining patient outcome after surgery. Further research is needed to clarify the clinical relevance of all forms and severity grades of steatosis for patient outcome. Standardized grading and diagnostic methods need to be used in future clinical trials to be able to compare outcomes of different studies.

The transporter specificity of (99m)Tc-mebrofenin and ICG partially overlaps as both compounds are transported by OATP1B3. (99m)Tc-mebrofenin is also taken up by OATP1B1, whereas ICG is additionally transported by NTCP. Accepted ManuscriptTransporters involved in the hepatic uptake of 99m Tc-mebrofenin and indocyanine green This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.