Background: The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery. Methods: An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery. Results: Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries. Conclusion: This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a "new" normal world with screening of patients and staff for COVID-19.
These data support the use of a central bisectionectomy in selected cases in the management of HCC. With the use of a meticulous operative technique and adherence to surgical oncological principles, satisfactory long-term outcomes were achievable.
Background: Acute calculous cholecystitis (ACC) is a common disease across the world and is associated with significant socioeconomic costs. Although contemporary guidelines support the role of early laparoscopic cholecystectomy (ELC), there is significant variation among units adopting it as standard practice. There are many resource implications of providing a service whereby cholecystectomies for acute cholecystitis can be performed safely. Methods: Studies that incorporated an economic analysis comparing early with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were identified by means of a systematic review. A meta-analysis was performed on those cost evaluations. The quality of economic valuations contained therein was evaluated using the Quality of Health Economic Studies (QHES) analysis score. Results: Six studies containing cost analyses were included in the meta-analysis with 1128 patients. The median healthcare cost of ELC versus DLC was €4400 and €6004 respectively. Five studies had adequate data for pooled analysis. The standardized mean difference between ELC and DLC was −2⋅18 (95 per cent c.i. −3⋅86 to −0⋅51; P = 0⋅011; I 2 = 98⋅7 per cent) in favour of ELC. The median QHES score for the included studies was 52⋅17 (range 41-72), indicating overall poor-to-fair quality. Conclusion: Economic evaluations within clinical trials favour ELC for ACC. The limited number and poor quality of economic evaluations are noteworthy.
C ontrolled donation after circulatory death (DCD) poses unique challenges in both logistics and ethics. After withdrawal of supportive treatment, often mechanical ventilation and vasopressors, respiratory distress, and movements consistent with discomfort are commonly observed. A situation arises, which conflicts between facilitating the individual's autonomous wish to donate their organs, the right for a dignified death, and the responsibility to optimize the quality of the organs donated. Best practice must reflect equally each of these ethical perspectives. Tracking the outcomes of potential DCD donors after withdrawal of support provides a valuable and overarching perspective on the nature of these challenges. We commend the authors in this issue's feature article 1 for their efforts and insights, as provocative as they may be.As the authors point out, there have been many reports, including their own, 2 attempting to predict whether DCD donors will expire in a timely manner consistent with organ donation. 2-6 However, it is worth noting that none of these tools have gained universal acceptance. The area under the receiver operating characteristic curve as an estimate of the predictive capacity of these models generally varies from 0.68 to 0.81. 7 Those models with a C-statistic less than 0.7 offer prediction that is only slightly better than chance alone. Moreover, even those with very good predictive capacity (C-statistic >0.8) still can suffer from poor discrimination, particularly in the center of the distribution, which is often where most patients fall. 8 In the setting of DCD donation, where the consequences of an inaccurate prediction is the loss of organs for transplant, the decision is often taken by a Medical Director with substantial experience regarding DCD as opposed to singular application of a decision support tool or unilateral Organ Procurement Organization (OPO) policy. Limited ability to predict the time of death reliably has led to suggestions that the DCD procedure should be used for every potential donor to avoid the loss of transplantable organs. 9 However, this approach is troublesome for grieving families, and resource intensive for hospitals, OPOs, and transplant centers. The present study is valuable but requires further refinement. 1 Unfortunately, the authors did not provide data regarding the prospective or retrospective application of their own University of Wisconsin DCD tool. 2 Further valuable insights into which prospective DCD donors are likely to expire according to a particular timeline for targeted application of their suggested conversion of DCD into living donors might alleviate some concerns regarding implementation of this provocative strategy.The success of DCD depends on appropriate policies for the withdrawal of life-sustaining treatments including the discontinuation of mechanical ventilation and vasopressor agents. In addition, specific protocols for the timing of interventions, such as the use of anticoagulant medications (eg, heparin), the mandatory waiting ...
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