Paul Karanicolas

BackgroundApproximately 15% of patients experience post-hepatectomy liver failure after major hepatectomy. Poor hepatocyte uptake of gadoxetate disodium, a magnetic resonance imaging contrast agent, may be a predictor of post-hepatectomy liver failure.MethodsA retrospective cohort study of patients undergoing major hepatectomy (≥3 segments) with a preoperative gadoxetate disodium-enhanced magnetic resonance imaging was conducted. The liver signal intensity (standardized to the spleen) and the functional liver remnant was calculated to determine if this can predict post-hepatectomy liver failure after major hepatectomy.ResultsIn 134 patients, low signal intensity of the remnant liver standardized by signal intensity of the spleen in post-contrast images was associated with post-hepatectomy liver failure in multiple logistic regression analysis (Odds Ratio 0.112; 95 % CI 0.023 – 0.551). In a subgroup of …

Objective:To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery.Background:The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain.Methods:We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty.Results:

Hepato-pancreato-biliary surgical oncology is a unique specialty in many ways. It encompasses a group of extremely aggressive cancers that require very complex and highly demanding medical and surgical treatment; however, probably one of its most distinctive features, very different from other specialties, is its role in the treatment of patients with metastatic disease, mainly from colorectal malignancies. Colorectal cancer accounted for more than 900,000 deaths worldwide in 2020, being the second most common cause of cancer death. 1 Approximately 25–30% of these patients present with metastases at diagnosis and 30% of this group will have liver metastases as the only site. 2, 3 To date, surgical resection is the only potentially curative strategy for patients with colorectal cancer liver metastases (CRLM), achieving a 5-year overall survival of approximately 50%; 4 however, 60–70% of patients will develop …

IntroductionSurgical stress results in immune dysfunction, predisposing patients to infections in the postoperative period and potentially increasing the risk of cancer recurrence. Perioperative immunonutrition with arginine-enhanced diets has been found to potentially improve short-term and cancer outcomes. This study seeks to measure the impact of perioperative immunomodulation on biomarkers of the immune response and perioperative outcomes following hepatopancreaticobiliary surgery.Methods and analysisThis is a 1:1:1 randomised, controlled and blinded superiority trial of 45 patients. Baseline and perioperative variables were collected to evaluate immune function, clinical outcomes and feasibility outcomes. The primary outcome is a reduction in natural killer cell killing as measured on postoperative day 1 compared with baseline between the control and experimental cohorts.Ethics and dissemination …

BackgroundRobot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures.Study designThis cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level.ResultsA total of 6814 patients were included, with …

ImportanceDespite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.ObjectiveTo define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.Design, Setting, and ParticipantsPragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or …

ASO Visual Abstract: Current Practices in Hepatic Artery Infusion (HAI) Chemotherapy-An International Survey of the HAI Consortium Research Network ASO Visual Abstract: Current Practices in Hepatic Artery Infusion (HAI) Chemotherapy-An International Survey of the HAI Consortium Research Network Ann Surg Oncol. 2023 Dec;30(13):8021-8022. doi: 10.1245/s10434-023-14281-x. Authors Sean J Judge 1 , Tara Ghalambor 2 , Michael J Cavnar 3 , Michael E Lidsky 4 , Ryan P Merkow 5 , May Cho 6 , Ismael Dominguez-Rosado 7 , Paul J Karanicolas 8 , Skye C Mayo 9 , Flavio G Rocha 9 , Ryan C Fields 10 , Reema A Patel 11 , Hagen F Kennecke 12 , Bas Groot Koerkamp 13 , Adam C Yopp 14 , Henrik Petrowsky 15 , Devalingham Mahalingam 16 , Nancy Kemeny 17 , Michael D'Angelica 1 , Sepideh Gholami 18 Affiliations 1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 2 …

Vatsaelinkirurgisten leikkausten laskimotukos- ja verenvuotoriskit vaihtelevat huomattavasti eri toimenpiteiden välillä — University of Helsinki Skip to main navigation Skip to search Skip to main content University of Helsinki Home University of Helsinki Logo English Svenska Suomi Home Persons Publications Projects Research Infrastructures Research Units Datasets Activities Prizes Press/Media Search by expertise, name or affiliation Vatsaelinkirurgisten leikkausten laskimotukos- ja verenvuotoriskit vaihtelevat huomattavasti eri toimenpiteiden välillä Lauri I. Lavikainen, Gordon H. Guyatt, Ville J. Sallinen, Paul J. Karanicolas, Rachel J. Couban, Tino Singh, Yung Lee, Jaana Elberkennou, Riikka Aaltonen, Kaisa Ahopelto, Ines Beilmann-Lehtonen, Marco H. Blanker, Jovita L. Cárdenas, Rufus Cartwright, Samantha Craigie, PJ Devereaux, Herney A. Garcia-Perdomo, Fang Zhou Ge, Huda A. Gomaa, Alex LE HalmeJari …

BackgroundMetformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age.MethodsMiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo …

BackgroundAn increasing number of hepatic artery infusion (HAI) programs have been established worldwide. Practice patterns for this complex therapy across these programs have not been reported. This survey aimed to identify current practice patterns in HAI therapy with the long-term goal of defining best practices and performing prospective studies.MethodsUsing SurveyMonkeyTM, a 28-question survey assessing current practices in HAI was developed by 12 HAI Consortium Research Network (HCRN) surgical oncologists. Content analysis was used to code textual responses, and the frequency of categories was calculated. Scores for rank-order questions were generated by calculating average ranking for each answer choice.ResultsThirty-six (72%) HCRN members responded to the survey. The most common intended initial indications for HAI at new programs were unresectable colorectal liver metastases …

IntroductionUp to 25% of colorectal cancer patients present with synchronous liver metastases that can be treated with two operations or a single ‘simultaneous’ operation. Morbidity and mortality appear similar between approaches, however changes in health-related quality-of-life following simultaneous resection are not well reported.MethodsA prospective, feasibility trial for simultaneous resection of synchronous colorectal liver metastases was conducted. Patients completed the European Organization for Research and Treatment of Cancer QLQ-C30 and LMC21 at baseline (preoperatively), and 4 and 12 weeks postoperatively. Week 4 and 12 scores were compared with baseline using t-tests. Minimally important clinical differences were considered as a 10-point difference from baseline.ResultsC30 and QLQ-LMC21 were completed at baseline, 4 weeks, and 12 weeks by 39 (95%), 35 (85%) and 34 (83 …

The resection margin status is a significant surgical prognostic factor for the long-term outcomes of patients undergoing pancreaticoduodenectomy (Whipple procedure). As a result, surgeons frequently rely on intraoperative consults (IOCs) involving frozen sections to evaluate margin clearance during these resections. Nevertheless, the impact of this practice on final margin status and long-term outcomes remains a topic of debate. This study aimed to assess the impact of IOCs on the clearance rate of resection margins following Whipple procedure and distal pancreatectomy. A retrospective database review of all patients who underwent Whipple procedure or distal pancreatectomy at our institution between 2018 and 2020 was performed to evaluate the utility of IOCs by gastrointestinal surgeons and its correlation with final postoperative surgical margin status. A significant variation in the frequency of IOC requests …

IntroductionRobotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery.MethodsThis population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach.ResultsThe cohort included 24,741 radical prostatectomy …

Objective:To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis.Background:Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined.Methods:Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent.Results:Of 778 participants in the clinical …

ObjectiveThis study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries.Data SourcesWe conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis.Study Eligibility CriteriaEligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L.Methods …

Introduction Contrast-enhanced MRI is routinely performed as part of preoperative work-up for patients with Colorectal Cancer Liver Metastases (CRLM). Radiomic biomarkers depicting the characteristics of CRLMs in MRI have been associated with overall survival (OS) of patients, but the reproducibility and clinical applicability of these biomarkers are limited due to the variations in MRI protocols between hospitals. Methods In this work, we propose a generalizable radiomic model for predicting OS of CRLM patients who received preoperative chemotherapy and delayed-phase contrast enhanced (DPCE) MRIs prior to hepatic resection. This retrospective two-center study included three DPCE MRI cohorts (n=221) collected between January 2006 and December 2012. A 10-minute delayed Gd-DO3A-butrol enhanced MRI discovery cohort was used to select features based on robustness across contrast agents, correlation with OS and pairwise Pearson correlation, and to train a logistic regression model that predicts 3-year OS. Results The model was evaluated on a 10-minute delayed Gd-DO3A-butrol enhanced MRI validation cohort (n=121), a 20-minute delayed Gd-EOB-DTPA (n=72) cohort from the same institute, and a 5-minute delayed Gd-DTPA cohort (n=28) from an independent institute. Two features were selected: minor axis length and dependence variance. The radiomic signature model stratified high-risk and low-risk CRLM groups in the Gd-DO3Abutrol (HR = 6.29, p = .007), Gd-EOB-DTPA (HR = 3.54, p = .003) and Gd-DTPA (HR = 3.16, p = .04) validation cohorts. Discussion While most existing MRI findings focus on a specific …

Background:Pancreaticoduodenectomy is the only curative option for patients with pancreatic cancer; however, pain remains a considerable problem postoperatively. With many centres moving away from using epidural analgesia, there is the need to evaluate alternative opiate sparing techniques for postoperative analgesia. We sought to determine if rectus sheath catheters (RSCs) had an opiate sparing and analgesic effect compared with standard care alone (opiate analgesia).Methods:We conducted a retrospective pre-and postintervention cohort study of patients undergoing pancreaticoduodenectomy at a single tertiary academic hospital in Toronto, Canada, between April 2018 and December 2019. All patients undergoing a pancreaticoduodenectomy were eligible for inclusion. Among the 101 patients identified, 84 (61 control, 23 RSCs) were analyzed after exclusion criteria were applied (epidural analgesia …

ImportanceThere is marked variability in red blood cell (RBC) transfusion during the intraoperative period. The development and implementation of existing clinical practice guidelines have been ineffective in reducing this variability.ObjectiveTo develop an internationally endorsed consensus statement about intraoperative transfusion in major noncardiac surgery.Evidence ReviewA Delphi consensus survey technique with an anonymous 3-round iterative rating and feedback process was used. An expert panel of surgeons, anesthesiologists, and transfusion medicine specialists was recruited internationally. Statements were informed by extensive preparatory work, including a systematic reviews of intraoperative RBC guidelines and clinical trials, an interview study with patients to explore their perspectives about intraoperative transfusion, and interviews with physicians to understand the various behaviors that …

Objective:To systematically review and meta-analyze whether the application of cryotherapy on closed incisions reduces postoperative pain and opioid consumption.Background:Reduction of acute pain and opioid use is important in the postoperative phase of patient care.‘‘Cryotherapy’’refers to the use of low temperatures for therapeutic purposes.Methods:MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Online registries of clinical trial were search until October 2019. RCT that examined postoperative application of cryotherapy over surgical incisions in adults compared to no cryotherapy were eligible. Selection, extraction, and risk of bias appraisal were completed in duplicate. Data were synthesized using random effects meta-analyses. The outcomes of interest were postoperative pain, opioid use, hospital length of stay (LOS) and surgical site infection (SSI).Results:Fifty-one RCTs (N …

BackgroundPost-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF.MethodsWe conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay …