Consensus and Controversy in Hepatic Surgery: A Survey of Canadian Surgeons JESSICA L. TRUONG, BHSc, 1 DAVID P. CYR, MSc, 1 JENNY LAM-MCCULLOCH, PhD, 1,2 SEAN P. CLEARY, MD, MSc, MPH, FRCSC, 2,3 AND PAUL J KARANICOLAS, MD, PhD, FRCSC 1,2 * 1 Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON 2 Department of Surgery, University of Toronto, Toronto, ON 3 Department of Surgery, University Health Network, Toronto, ON Background: Heterogeneity in practice provides an opportunity for further study, as it may [IRT Rev 1] reflect deficiencies in knowledge translation or knowledge gaps. This survey aimed to assess practice patterns for the surgical treatment of malignancies of the liverwith the goal of identifying areas of variability. Methods: We created a web‐based survey focusing on scope of surgical practice, pre‐and post‐operative measures and practice patterns for liver and biliary surgery. We piloted the survey for clarity and made changes as needed. All members of the Canadian Hepato‐Pancreatico‐Biliary Association (CHPBA) were invited to participate. Descriptive statistics were used to analyze the results. Results: The survey was sent to sixty‐nine surgeons and thirty‐six (52%) completed the survey in its entirety. Areas of agreement include defining the resectability of a tumourand in imaging modalities used to determine resectability. Variability surrounded utlilization of blood conservation strategies, withlow CVP anesthesia frequently used and all other strategies (autologous blood donation, acute normovolemic hemodilution, cell‐ saver, and tranexamic acid) rarely used. Post‐operative analgesic technique was variable with epidural analgesia (50%) and IV‐PCA (35.3%) nearly equally preferred. Conclusions: There is variability in some techniques and approaches used by hepatobiliary surgeons. Future research focusing on areas of uncertainty including techniques of blood conservation and post‐operative analgesia are needed. J. Surg. Oncol. 2014;110:947–951. ß 2014 Wiley Periodicals, Inc. KEY WORDS: hepatic surgery; liver metastases; survey; variability; technique INTRODUCTION Expert consensus and strong evidence that an intervention is effective yields little or no variation in clinical practice [1]. In contrast, heterogeneity in practice may reflect equivalency or non‐inferiority in technique or practice [IRT Rev 1], a failure to deliver evidence‐based care, patient and physician preferences, limited resources in supply‐ sensitive care, or knowledge deficits (i.e. lack of evidence) [2]. There is potential for variability in every aspect of a patient encounter: the way diagnoses and illnesses are expressed, the treatment responses and preferences of patients, the skills and training of physicians, etc. Ideally the negative variation that can adversely affect patient care should be minimized while preserving variation reflective of patient‐centered care [3]. In any of these cases, areas of variability must be identified and the available evidence explored and expanded upon where appropriate. [IRT Rev 1] With the development of new surgical techniques, chemotherapy, and imaging, there are several areas for considerable variation in surgical practice regarding liver resection. Variation in practice has been noted previously across cancer networks in England [4]. More recently in a scenario‐based survey, surgeons disagreed on the resectability and use of adjunct modalities in the treatment of colorectal cancer liver metastases [5]. Another team noted similar heterogeneity in the role of neoadjuvant therapy vs upfront surgery, radio frequency ablation, and downstaging chemotherapy in the treatment of hepatic colorectal cancer metastases [6]. The authors of another study suggested recently that a gap exists between current practice and best evidence for the management of hepatic colorectal cancer metastases [7]. [IRT Rev 2] We sought to assess practice patterns across Canadian hepatobiliary surgeons regarding treatment of colorectal liver metastases focusing onassessment of resectability, intraop erative techniques, and post‐operative measures. MATERIALS AND METHODS We developed a survey composed of 34 questions divided into five main sections: (i) Training and practice; (ii) Scope of Liver and Biliary Surgical Practices; (iii) Pre‐operative measures specific to liver resections as treatment for colorectal liver metastases; (iv) Peri‐ operative measures for liver resections; (v) Follow‐up measures specific to liver resections as treatment for colorectal liver metastases. The survey was piloted amongst three HPB surgeons, with corresponding changes made regarding its ease of use and clarity. We utilized the Dillman survey methodology to maximize response rate [8]. The survey was sent using an online platform (SurveyMonkey 1 ) to 69 surgeons across Canada, identified by membership with the Canadian Hepato‐Pancreato‐Biliary Association (CHPBA) or by Abbreviations: CHPBA, canadian hepato‐pancreatico‐biliary association; CVP, central venous pressure; IV‐PCA, intravenous patient‐controlled analgesia; HPB‐CONCEPT, hepato‐pancreatico‐biliary community of surgical oncologists: clinical, evaluative, and prospective trials team; CRC, colorectal cancer; ANH, acute normovolemic hemodilution; TAP, transversus abdominal plane; CUSA, cavitron ultrasonic surgical aspirator; RF, radiofrequency. Conflict of Interest: The authors declare that they have no conflict of interest *Correspondence to: Paul Karanicolas, MD, PhD, FRCSC, Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5 Canada. Tel: (416) 480‐4832; Fax: (416) 480‐6002. E‐mail: paul.karanicolas@sunnybrook.ca Received 27 April 2014; Accepted 16 July 2014 DOI 10.1002/jso.23748 Published online 22 August 2014 in Wiley Online Library (wileyonlinelibrary.com). Journal of Surgical Oncology 2014;110:947–951 ß 2014 Wiley Periodicals, Inc.