Spontaneous discharge of 'spilled gallstone' with complete resolution of retroperitoneal abscess in a patient treated for putative tuberculosis

A 76-year-old man presented 5 months following an open cholecystectomy with a complicated retroperitoneal abscess secondary to a retained gallstone, which was misdiagnosed as a tuberculous abscess. Subsequently, the stone was eventually spontaneously discharged with complete resolution of the associated collection.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A PubMed and Medline literature review was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy, followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can be effectively treated by aspiration or drainage.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.

Preoperative biliary drainage for distal biliary obstruction and post-operative infectious complications

BACKGROUND

Preoperative biliary drainage (PBD) for distal bile duct obstruction may increase post-operative complications. This study examined the effect of PBD on positive bile culture (PBC) rates and complications after biliary bypass or pancreaticoduodenectomy. Bilirubin levels in the non-PBD cohort were also analysed to determine the impact on outcome.

METHODS

A retrospective case-note analysis from 2005 to the present day was undertaken. Statistical analysis was undertaken using Students's t-test, chi-squared test, receiver operator characteristics, correlation coefficient and relative risk ratios.

RESULTS

A total of 422 patients were identified undergoing pancreaticoduodenectomy or biliary bypass for either benign or malignant distal biliary obstruction. One hundred ninety-six patients had complete data regarding PBD and bile cultures. PBD resulted in a significantly higher relative risk of both infectious complications and positive bile cultures. Overall complication rate was greater in patients undergoing PBD. The major complication rate was equivalent between the two groups. Bilirubin levels in the non-PBD cohort did not correlate or predict length of stay, high-dependency stay, and mortality or complication rate.

CONCLUSION

There seems to be little value in PBD for patients with distal biliary obstruction other than to defer definitive surgery to a non-emergency setting. For most hepato-pancreato-biliary units, avoidance of PBD will prove logistically difficult.

Single-incision laparoscopic cholecystectomy: a systematic review

OBJECTIVES

To compare the morbidity, pain, cosmesis, and cost-effectiveness of single-incision laparoscopic cholecystectomy (SILC) with standard laparoscopic cholecystectomy (SLC).

DATA SOURCES

Existing literature in MEDLINE through July 31, 2011.

STUDY SELECTION

We reviewed all studies identified through MEDLINE. References were cross-checked to ensure capture of cited pertinent articles. Case reports and series of less than 4 cases were excluded.

DATA SYNTHESIS

In total we analyzed 49 studies, including 2336 patients. Seven studies consisted of randomized trials and 11 of case-matched control series (compared with SLC). The technical aspects of SILC were not standardized. Median follow-up time was 4 weeks, although 27 studies (55.1%) reported no follow-up. The overall median complication rate was 7.37% (range, 0-28.6%), and the overall rate of biliary duct complications was 0.39%. Postoperative pain was similar or worse in SILC compared with SLC in 10 of 13 articles reporting pain outcomes (76.9%). Six articles investigating cosmesis after SILC compared outcomes with those of SLC. Three articles demonstrated significantly improved cosmesis after SILC.

CONCLUSIONS

The perceived benefits of SILC compared with SLC are improved cosmesis and reduced surgical trauma. No definitive evidence suggests that such improvements can be gained by SILC. Complications are more common, may be underestimated owing to the lack of sufficient follow-up, and may be associated with a shift from safe practice.

The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review

OBJECTIVES

Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD.

METHODS

A systematic review of articles containing relevant search terms was performed.

RESULTS

Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation's specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III.

CONCLUSIONS

Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox(TM) or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.

Management of acute non-cirrhotic and non-malignant portal vein thrombosis: a systematic review

BACKGROUND

No definitive evidence exists regarding the treatment of acute portal vein thrombosis (PVT). Treatment modalities described include conservative management, anticoagulation, thrombolysis, and thrombectomy. This review examines the impact of such treatment, its outcomes, and the complications resulting from the resultant portal hypertension.

METHODS

A Medline literature search was undertaken using the keywords portal vein thrombosis, anticoagulation, thrombolysis, and thrombectomy. The primary end point was portal vein recanalization. Secondary outcome measures were morbidity and the development of portal hypertension and its sequelae, including variceal bleeding. Data from articles relating to PVT in the context of cirrhosis, malignancy, or liver transplant were excluded.

RESULTS

Early systemic anticoagulation results in complete portal vein recanalization in 38.3% of cases and partial recanalization in 14.0% of cases. Spontaneous recanalization without treatment can only be expected in up to 16.7% of patients. Frequently this is only when associated with self-limiting underlying pathology and/or minimal thrombus extension. Thrombolysis can be associated with major complications in up to 60% of patients.

CONCLUSIONS

The natural history of acute PVT is poorly described. Spontaneous resolution of acute portal vein thrombosis is uncommon. Early anticoagulation results in a satisfactory rate of recanalization with minimal procedure-associated morbidity. Thrombolysis should be used with caution and only considered if the disease is progressive and signs of mesenteric ischemia are present. Further well-designed trials with precise outcome reporting are needed to improve our understanding of the disease.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

Factors predicting significant pathology on ultrasonography in women presenting with non-specific lower abdominal pain

INTRODUCTION

Ultrasonography is used frequently to exclude significant pathology in young women presenting with non-specific lower abdominal pain (NSLAP). This study examined parameters that predicted the likelihood of significant findings on ultrasonography. These results could be used to select patients for priority imaging or identify those who could be managed with no ultrasonography.

METHODS

A total of 65 women with NSLAP were identified from 283 admissions. Group 1 (n=42) consisted of patients with normal imaging. Group 2 (n=23) included patients with 'positive' scans requiring treatment. White cell count (WCC), C-reactive protein (CRP) levels, platelet count, age, duration of pain and length of stay in hospital were compared between the groups.

RESULTS

The median WCC and CRP were greater in Group 2 than in Group 1: 15 x 10(9)/l and 123 mg/l versus 11 x 10(9)/l and 72 mg/l respectively (p=0.01 and p=0.05). CRP was a weak predictor of positive pathology on ultrasonography (area under curve [AUC]=0.66, p=0.027) and WCC was a strong predictor of abnormal pathology on ultrasonography (AUC=0.7, p=0.005). A WCC of >12.8 x 10(9)/l was 65% sensitive and 71% specific in predicting subsequent pathology on ultrasonography. The median wait for ultrasonography was 24 hours (range: 1-96 hours).

CONCLUSIONS

This study failed to define any criteria that could select patients not requiring ultrasonography. Since ultrasonography is a relatively cheap and safe investigation, its continued use to screen women with NSLAP is justified. WCC should be used to prioritise imaging.

A rare case of multi-focal angiomyolipoma affecting the pancreas and liver

Angiomyolipoma (AML) are benign tumours composed of varying amounts of thick-walled dysplastic blood vessels, smooth muscle and mature adipose tissue derived from epithelioid cells. We present a previously unreported occurrence of multi-focal pancreatic and hepatic AMLs in a patient and discuss the diagnostic and management difficulties associated with this rare disease. In addition relevant case studies are also reviewed.

Evaluation of nurse-led discharge following laparoscopic surgery

INTRODUCTION

The United Kingdom's Department of Health has identified reducing delays in patient discharge as a key aim for Health Service development. Laparoscopic cholecystectomy and laparoscopic inguinal hernia repair may be safely performed on a short stay basis, but day case rates remain low, with delays in discharge identified as a major contributing factor. Nurse-led discharge has been widely advocated to speed patient discharge across varied specialities, but objective evidence to support its use is lacking. This study aimed to assess the effectiveness of nurse-led discharge following laparoscopic surgery.

METHODS

A retrospective comparison of doctor-led and nurse-led discharge following laparoscopic surgery was performed by analysis of two consecutive 4-month periods, prior to and following the introduction of nurse-led discharge by a laparoscopic nurse specialist. Outcomes assessed included time to discharge, reasons for delayed discharge, hospital readmissions and primary care episodes following discharge.

RESULTS

A total of 128 patients were included in the study, with each discharge group containing 64 patients. Patients in the nurse-led discharge group were significantly more likely to be discharged on the day of surgery than patients in the doctor-led discharge group (17.2% vs. 4.7%; P = 0.023), with a highly significant difference in same day discharge rates noted among patients operated on during morning theatre lists (44.0% vs. 10.7%; P = 0.006). There was no significant difference between the discharge groups in readmission rates or in the number of patients seeking primary care attention following discharge.

CONCLUSIONS

Nurse-led discharge may speed discharge following laparoscopic surgery with no apparent detriment to patient care.

Pancreaticogastric fistula secondary to intraductal papillary mucinous neoplasia: a case report and review of the literature

Intraductal papillary mucinous neoplasms (IPMNs) are benign cystic lesions of the pancreas with recognised premalignant potential. An occasional feature of IPMNs is fistula formation to surrounding organs. This report describes a case of a pancreaticogastric fistula from a main duct IPMN that produced the complete resolution of the patient's symptoms.

Preoperative neutrophil-to-lymphocyte ratio (NLR) is associated with reduced disease-free survival following curative resection of pancreatic adenocarcinoma

BACKGROUND

Serological proinflammatory markers such as C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) have been associated with reduced survival for many different types of cancer. This study determined the prognostic value of the preoperative value of these markers in patients with resectable pancreatic adenocarcinoma.

METHODS

Consecutive patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were entered into our database from 2001 to the present day. CRP, NLR, and PLR at the time of presentation were recorded as well as overall and disease-free survival.

RESULTS

Seventy-four patients were identified. Overall median survival was 35.0 months and median disease-free survival was 27.0 months. Follow-up ranged from 1 to 125.8 months. Preoperative NLR was significantly greater in those patients who developed recurrence in the follow-up period (4.5 vs. 3.1). CRP and PLR were not found to differ significantly between the two groups. Kaplan-Meier survival analysis of patients with NLR > 5 demonstrated a disease-free survival of 12 months compared with 52 months for those patients with NLR < 5 (p < 0.001).

CONCLUSION

Preoperative NLR offers important prognostic information regarding disease-free survival following curative resection of pancreatic ductal adenocarcinoma.

Branch-type intraductal papillary mucinous neoplasms: an update

BACKGROUND/AIMS

Branch-type intraductal papillary mucinous neoplasms (BT-IPMNs) are a subset of non-inflammatory mucinous lesions of the pancreas. Selected BT-IPMNs can be managed conservatively by surveillance because of their lower malignant potential. This review aims to update the reader on advances in our knowledge of BT-IPMNs since the consensus guidelines published in 2006.

METHODS

A Pubmed search for BT-IPMNs was undertaken and relevant papers were reviewed.

RESULTS

Due to the relative scarcity of this condition, still little is known about the natural history, the best method of surveillance or the surgical and non-surgical options.

CONCLUSION

A national database of BT-IPMNs would enable a large enough cohort of patients to be followed up and valid conclusions drawn regarding the best method of treatment or surveillance. and IAP.

Preoperative systemic inflammation and infectious complications after resection of colorectal liver metastases

BACKGROUND

Postoperative complications are associated with a poor long-term prognosis after resection of colorectal liver metastases via an undetermined mechanism. The preoperative systemic inflammatory response, itself a predictor of poor survival, was recently shown to independently predict postoperative infectious complications after primary colorectal cancer resection.

OBJECTIVE

To examine the association of postoperative infectious complications with preoperative systemic inflammation and survival in patients undergoing resection of colorectal liver metastases.

DESIGN

Retrospective study based on a prospectively updated database.

SETTING

A United Kingdom tertiary referral hepatobiliary unit.

PATIENTS

A total of 202 consecutive patients with colorectal liver metastases undergoing hepatectomy between January 1, 2000, and April 30, 2006.

MAIN OUTCOME MEASURES

Multivariable analyses were performed to correlate preoperative and operative variables with postoperative complications and to correlate complications with long-term survival after metastasectomy.

RESULTS

Ninety-day mortality and morbidity were 2.0% and 25.7%, respectively. The preoperative systemic inflammatory response independently predicted the development of infectious complications (P = .009) and major infectious complications (P = .005) after hepatectomy, along with performance of trisectionectomy. Infectious complications were associated with poor long-term survival after metastasectomy but lost independent significance when systemic inflammatory variables were included in multivariable analyses.

CONCLUSIONS

The preoperative systemic inflammatory response independently predicts the development of infectious complications after colorectal liver metastases resection. Although infectious complications are associated with adverse long-term prognosis after hepatectomy, they lacked independent prognostic value when systemic inflammatory variables were also considered, suggesting that much of their prognostic value arises from their association with the preoperative systemic inflammatory response.

Bilirubin levels predict malignancy in patients with obstructive jaundice

BACKGROUND

Differentiating between benign and malignant causes of obstructive jaundice can be challenging, even with the advanced imaging and endoscopic techniques currently available. In patients with obstructive jaundice, the predictive accuracy of bilirubin levels at presentation was examined in order to determine whether such data could be used to differentiate between malignant and benign disease.

METHODS

A total of 1,026 patients with obstructive jaundice were identified. Patients were divided into benign and malignant groups. The benign patients were subgrouped into those with choledocholithiasis and those with inflammatory strictures of the biliary tree. Bilirubin levels at presentation and other demographic data were obtained from case records.

RESULTS

Area under the curve (AUC) values for bilirubin as a predictor of malignancy were highly significant for all benign presentations and for those with benign biliary strictures (AUC: 0.8 for both groups; P < 0.001). A bilirubin level > 100 µmol/l was determined to provide the optimum sensitivity and specificity for malignancy in all patients and in those without choledocholithiasis (71.9% and 86.9%, 71.9% and 88.0%, respectively). The application of a bilirubin level > 250 µmol/l achieved specificities of 97.1% and 98.0% in each subgroup of patients, respectively.

CONCLUSIONS

In patients with obstructive jaundice, bilirubin levels in isolation represent an important tool for discriminating between benign and malignant underlying causes.

An isolated cardiac metastasis from colorectal adenocarcinoma

Epidemiological information relating to cardiac metastases is predominantly based on autopsy studies. The reported incidence ranges from 2.3-18.3%. It is usually found in the presence of widely disseminated disease. Here, a case of an isolated, asymptomatic cardiac metastasis from colonic adenocarcinoma is reported. The metastasis was detected later, following bowel resection and was not amenable to surgical resection. The patient is receiving ongoing care from the oncology team.

A simple, safe technique for the drainage of pancreatic pseudocysts

BACKGROUND

A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long-term results of this approach.

METHODS

This is a retrospective study of patients undergoing combined endoscopic/ultrasound-guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database.

RESULTS

Thirty-seven combined endoscopic/ultrasound-guided procedures were undertaken. Median patient age was 52 years (range 26-84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre-procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1-44 days) and 30-day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow-up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months.

CONCLUSION

Combined radiological and endoscopic drainage is safe, cost-effective and highly efficient in preventing recurrent pseudocyst formation.

Abdominal adhesion prevention: still a sticky subject?

BACKGROUND

Adhesion formation remains an almost inevitable consequence of abdominal procedures, potentially resulting in significant morbidity and mortality. There is an ongoing need to evaluate current understanding of adhesion formation and products aimed at prevention. Failure to keep up to date with adhesion treatment may subject clinicians to a greater medico-legal risk.

DESIGN

Review of published studies exploring the problem of peritoneal adhesion formation. This encompasses the underlying processes of adhesion formation combined with general approaches to reduce formation. An overview of products trialled to prevent formation in both the animal model and clinical setting describes products of scientific interest and commercial success.

RESULTS

Advances in surgical technique, such as laparoscopic surgery, can help minimize the probability of adhesion formation. Currently barrier products, whilst reducing adhesion formation, have not been shown to reduce the risk of readmission with complications related to adhesions. Hybrid products may improve upon this situation.

CONCLUSIONS

No single approach has been wholly satisfactory in reducing adhesions. Research into the processes driving adhesion formation is providing exciting new targets for therapeutic agents. It would seem plausible that with many promising avenues of research a revolutionary agent to reduce the incidence of adhesional small bowel obstruction may result.

Use of a modified chitosan-dextran gel to prevent peritoneal adhesions in a rat model

BACKGROUND

Intra-abdominal adhesions are a major cause of morbidity and a significant drain on healthcare resources. Numerous anti-adhesion products have reached clinical use but none has been wholly satisfactory. This study examines the application of a modified chitosan-dextran (CD) gel to the intraperitoneal cavity to reduce adhesion formation. This is a unique synthetic gel, its active ingredients being succinyl chitosan and dextran aldehyde.

MATERIALS AND METHODS

Eighty adult male Wistar albino rats were randomized to undergo surgery alone or to receive CD gel at the time of surgery. Control groups using modified dextran only gel were also included. The surgical procedures comprised of laparotomy and either cecal abrasion or anastomotic simulation by enterotomy of the cecum with primary closure. At postoperative d 21 rats were euthanized by CO2 inhalation, and adhesions graded by an investigator blinded to the treatment groups, using a predetermined adhesion measurement score.

RESULTS

Adhesions were significantly reduced in the cecal abrasion group with median adhesion scores for the treatment group of 0 versus 3 in the control group (P<0.001, Fisher's exact test). Further reduction in adhesion formation was noted in the enterotomy group with median scores of 2 versus 5 for treatment and control groups respectively (P=0.003, Fisher's exact test).

CONCLUSIONS

Chitosan-dextran gel appears to significantly reduce the formation of intra-abdominal adhesions without adversely affecting wound healing. This is a noteworthy advancement in the safe prevention of post operative, intra-abdominal adhesions.

Caveat reporting in ultrasound interpretation of surgical pathology: a comparison of sonographer versus radiologist

BACKGROUND

Radiology reports provide specialist interpretation of images and relate these findings to the patient's symptoms and signs. This study compared ultrasound (USS) reports generated by radiologists and sonographers to determine if any significant or clinically relevant differences existed.

METHODS

A retrospective analysis of 624 consecutive USS reports was carried out. The reports were assessed for the presence of a 'disclaimer' or 'caveat' pertaining to the quality of the images and were analysed with respect to the clarity of their wording and ability to answer the clinical request.

RESULTS

The majority of sonographer USS reports contained a disclaimer regarding the quality of the USS images (57.1%) compared with a smaller proportion of radiologist scans (9.9%) (P < 0.001). Overall, radiologists performed significantly better in providing a clear negative or positive diagnosis to the clinical question on the request form, when compared with sonographers (88.5% vs. 65.4%, P < 0.001).

CONCLUSION

'Disclaimer' comments and 'hedging' must be avoided in radiology reporting. While feedback as to the accuracy of the radiology images is important, overuse of such terms undermines the validity of the radiology report.

Predicting liver failure following major hepatectomy

Pre-operative determination of the risk of liver dysfunction has come under criticism with regards to its usefulness in clinical practice. Opinion is split between centres which use such tests uniformly on all patients and those where clinical judgment alone is used. Published data would not suggest any difference in mortality, morbidity or liver failure rates between these groups. This review outlines and presents the evidence for pre-operative quantification of functional liver remnant volume.