Systematic review of novel ablative methods in locally advanced pancreatic cancer

Unresectable locally advanced pancreatic cancer with or without metastatic disease is associated with a very poor prognosis.Current standard therapy is limited to chemotherapy or chemoradiotherapy.Few regimens have been shown to have a substantial survival advantage and novel treatment strategies are urgently needed.Thermal and laser based ablative techniques are widely used in many solid organ malignancies.Initial studies in the pancreas were associated with significant morbidity and mortality,which limited widespread adoption.Modifications to the various applications,in particular combining the techniques with high quality imaging such as computed tomography and intraoperative or endoscopic ultrasound has enabled real time treatment monitoring and significant improvements in safety.We conducted a systematic review of the litera-ture up to October 2013.Initial studies suggest that ablative therapies may confer an additional survival benefit over best supportive care but randomised studies are required to validate these findings.

Small for size syndrome following living donor and split liver transplantation

The field of liver transplantation is limited by the availability of donor organs. The use of living donor and split cadaveric grafts is one potential method of expanding the donor pool. However, primary graft dysfunction can result from the use of partial livers despite the absence of other causes such as vascular obstruction or sepsis. This increasingly recognised phenomenon is termed "Small-for-size syndrome" (SFSS). Studies in animal models and humans have suggested portal hyperperfusion of the graft combined with poor venous outflow and reduced arterial flow might cause sinusoidal congestion and endothelial dysfunction. Graft related factors such as graft to recipient body weight ratio < 0.8, impaired venous outflow, steatosis > 30% and pro- longed warm/cold ischemia time are positively predictive of SFSS. Donor related factors include deranged liver function tests and prolonged intensive care unit stay greater than five days. Child-Pugh grade C recipients are at relatively greater risk of developing SFSS. Surgi- cal approaches to prevent SFSS fall into two categories: those targeting portal hyperperfusion by reducing inflow to the graft, including splenic artery modulation and portacaval shunts; and those aiming to relieve paren-chymal congestion. This review aims to examine thecontroversial diagnosis of SFSS, including current strate-gies to predict and prevent its occurrence. We will also consider whether such interventions could jeopardize the graft by compromising regeneration.

Role of colectomy in preventing recurrent primary sclerosing cholangitis in liver transplant recipients

AIM To study the published evidence on the impact of colectomy in preventing recurrent primary sclerosing cholangitis(r PSC). METHODS An unrestricted systematic literature search in Pub Med, EMBASE, Medline Ovid SP, ISI Web of Science, Lista(EBSCO) and the Cochrane library was performed on clinical studies investigating colectomy in liver transplantation(LT) recipients with and without r PSC in the liver allograft. Study quality was evaluated according to a modification of the methodological index for non-randomized studies(MINORS) criteria. Primary endpoints were the impact of presence, timing and type of colectomy on r PSC. Overall presence of inflammatory bowel disease(IBD), time of IBD diagnosis, posttransplant IBD and immunosuppressive regimen were investigated as secondary outcome.RESULTS The literature search yielded a total of 180 publications. No randomized controlled trial was identified. Six retrospective studies met the inclusion criteria of which 5 studies were graded as high quality articles. Reporting of IBD was heterogenous but in four publications, either inflammatory bowel disease, ulcerative colitis or in particular active colitis post-LT significantly increased the risk of r PSC. The presence of an intact(i.e., retained) colon at LT was identified as risk factor for r PSC in two of the high quality studies while four studies found no effect. Type of colectomy was not associated with r PSC but this endpoint was underreported(only in 33% of included studies).Neither tacrolimus nor cyclosporine A yielded a significant benefit in disease recurrence of primary sclerosing cholangitis(PSC).CONCLUSION The data favours a protective role of pre-/peri-LT colectomy in r PSC but the current evidence is not strong enough to recommend routine colectomy for r PSC prevention.