The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England

INTRODUCTION

Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis.

METHODS

Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression.

RESULTS

In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively.

CONCLUSION

Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.

Management standards and burnout among surgeons in the United Kingdom

BACKGROUND

Burnout arising from chronic work-related stress is endemic among surgeons in the UK. Identification of contributory and modifiable psychosocial work characteristics could inform risk reduction activities.

AIMS

We aimed to assess the extent to which surgeons' psychosocial working conditions met aspirational Management Standards delineated by the UK Health and Safety Executive, draw comparisons with national general workforce benchmarks and explore associations with burnout.

METHODS

Surgeons (N = 536) completed the Management Standards Indicator Tool and a single-item measure of burnout. Descriptive data were computed for each Standard, independent t-tests were used to examine differences between trainees and consultants, and hierarchical linear regression was applied to explore relations between psychosocial work environment quality and burnout.

RESULTS

Psychosocial work environment quality fell short of each Management Standard. Trainee surgeons (n = 214) reported significantly poorer psychosocial working conditions than consultant surgeons (n = 322) on the control, peer support and change Standards. When compared with UK workforce benchmarks, trainees' psychosocial working conditions fell below the 10th percentile on four Standards and below the 50th percentile on the remainder. Consultant surgeons were below the 50th percentile on five of the seven Standards. Psychosocial working conditions accounted for 35% of the variance in burnout over that accounted for by socio- and occupational-demographic characteristics.

CONCLUSIONS

Surgeons' psychosocial working conditions were poor in comparison with benchmark data and associated with burnout. These findings suggest that risk management activities based on the Management Standards approach involving modification of psychosocial working conditions would help to reduce burnout in this population.

Identification of Surgeon Burnout via a Single-Item Measure

BACKGROUND

Burnout is endemic in surgeons in the UK and linked with poor patient safety and quality of care, mental health problems, and workforce sustainability. Mechanisms are required to facilitate the efficient identification of burnout in this population. Multi-item measures of burnout may be unsuitable for this purpose owing to assessment burden, expertise required for analysis, and cost.

AIMS

To determine whether surgeons in the UK reporting burnout on the 22-item Maslach Burnout Inventory (MBI) can be reliably identified by a single-item measure of burnout.

METHODS

Consultant (n = 333) and trainee (n = 217) surgeons completed the MBI and a single-item measure of burnout. We applied tests of discriminatory power to assess whether a report of high burnout on the single-item measure correctly classified MBI cases and non-cases.

RESULTS

The single-item measure demonstrated high discriminatory power on the emotional exhaustion burnout domain: the area under the curve was excellent for consultants and trainees (0.86 and 0.80), indicating high sensitivity and specificity. On the depersonalisation domain, discrimination was acceptable for consultants (0.76) and poor for trainees (0.69). In contrast, discrimination was acceptable for trainees (0.71) and poor for consultants (0.62) on the personal accomplishment domain.

CONCLUSIONS

A single-item measure of burnout is suitable for the efficient assessment of emotional exhaustion in consultant and trainee surgeons in the UK. Administered regularly, such a measure would facilitate the early identification of at-risk surgeons and swift intervention, as well as the monitoring of group-level temporal trends to inform resource allocation to coincide with peak periods.

Opioid prescription at postoperative discharge: a retrospective observational cohort study

Opioid misuse is now considered a major public health epidemic in North America, with substantial social and financial consequences. As well as socio-economic and commercial drivers, modifiable risk-factors that have resulted in this crisis have been identified. The purpose of this study was to identify whether, within England, modifiable drivers for persistent postoperative opioid use were present. This was a retrospective cohort study of practice at 14 National Health Service hospitals across England. Data were collected retrospectively and validated for adult patients undergoing elective intermediate and major or complex major general surgical procedures between 1 and 31 March 2019. Of the 509 patients enrolled from 14 centres, 499 were included in the data analysis. In total, 31.5% (157/499) patients were in the intermediate surgery cohort and 68.5% (342/499) were in the major or complex major surgery cohort, with 21.0% (33/157) and 21.6% (74/342) discharged with opioid medicines to be taken at regular intervals, respectively. There were similar median oral morphine equivalent doses prescribed at discharge. Of patients prescribed regular opioid medicines, 76.6% (82/107) had a specified duration at discharge. However, 72.9% (78/107) had no written deprescribing advice on discharge. Similarly, of patients prescribed 'when required' opioids, 59.6% (93/156) had a specified duration of their prescription and 33.3% (52/156) were given written deprescribing advice. This study has identified a pattern of poor prescribing practices, a lack of guidance and formal training at individual institutions and highlights opportunities for improvement in opioid-prescribing practices within England.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study

BACKGROUND

Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up.

METHODS

A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment.

RESULTS

A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery.

CONCLUSION

This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

O23 Outcomes after non-operative management of perforated diverticular disease: a population based cohort study

Introduction

The management of perforated diverticular disease has changed in the last 10 years with a move towards less surgical intervention. This population based cohort study aimed to define the risk of mortality and readmission following non-operative management of perforated diverticular disease (DD).

Method

Patients diagnosed with perforated DD and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case-fatality, re-admissions and surgery at re-admission.

Result

In total, 880 patients with perforated DD were managed without surgery, comprising of 523 females (59.4%). One year case-fatality was 33.2% (293/880). The majority of deaths occurred in the first 90 days following the index admission with a 90 day case-fatality of 28.8%. 90 day survival varied by age with 97.2% survival at 90 days in those under 65 years compared to 85.0% in those between 65–74 years and 51.5% in those over 75 years.

Of 767 patients discharged from hospital, 250 (32.6%, 250/767) were re-admitted (47 elective(6.1%) and 203 emergency(26.5%)) during a median of 1.6 years of follow-up (iqr 0.1–3.9 years) with similar proportions in each age category. In the first year of follow-up only 5.1% of patients required surgery of whom 16/767 (2.1%) required elective and 23/767 (3.0%) emergency surgery.

Conclusion

Conservative management of perforated diverticulitis in those under 65 years is feasible and safe. A third of patients are readmitted during follow-up, however, re-intervention rates following conservative management were low across all age categories.

Take-home Message

In younger patients (&lt;65yrs) conservative management of perforated diverticulitis is feasible and safe. A third of conservatively managed patients are readmitted during follow-up, however, need for surgery on readmission is rare.

O35 The impact of COVID-19 on access and availability of radiological imaging and surgical intervention at the east Midlands major trauma centre: an icon trauma study

Introduction

During the COVID-19 pandemic, Major Trauma services were subject to significant challenges including reduced access to Computed Tomography (CT) scanning and restrictions on operative intervention due to limited intensive care beds. This study evaluated the pandemic’s impact on access and timeliness of imaging and surgical intervention.

Method

This observational study compared 2 cohorts of patients admitted in a 10-week period during the COVID-19 pandemic and a similar time period in 2019. Variables included demographics, time to CT scan and to surgery and operative characteristics. Statistical comparisons were undertaken using Mann Whitney U, Fisher’s exact and Chi-squared tests.

Result

Of 642 patients, 405 were admitted in 2019 and 237 in 2020 representing a 41.5% absolute reduction in trauma admissions during the pandemic. There were no statistical differences (P = 0.2585) between arrival to the Emergency Department and time to CT scan across both years (median 42 minutes) or between operative approach (P = 0.728) and level of post-operative care (P = 0.788). However, there were statistical differences in time to surgery (P = 0.0193) and operative length (P = 0.0141) with a 2-fold increase in overnight operating, 31.2% increase in patients operated on &lt; 24 hours from admission, and 42.9% reduction in surgery lasting &gt;120 minutes during the COVID-19 pandemic.

Conclusion

Early robust restructuring of trauma services during the COVID-19 pandemic ensured timely access to appropriate imaging and surgery for major trauma injured patients. The higher rates of overnight surgery and shorter duration of procedure were likely explained by the increased onsite availability of suitably trained trauma surgical teams.

Take-home Message

COVID-19 had the potential to significantly impact Major Trauma services, however excellence in patient care was maintained by quick restructuring to staff, space and services Improvements to the Major Trauma pathway have become ingrained into daily practice and optimised for future outbreaks.

O2 Mortality following elective and emergency colorectal surgery in patients with cirrhosis: a population-based cohort study

Introduction

This population based cohort study, aimed to quantify the risk of mortality following colectomy in patients with cirrhosis by urgency of surgery and stage of cirrhosis.

Method

Linked primary and secondary-care electronic healthcare data from England was used to identify all patients undergoing colectomy from January 2001 to December 2017. Patients were classified into three cohorts, non-cirrhotics, compensated cirrhotics and decompensated cirrhosis and followed up for 90-days from the date of surgery. Cox proportional hazards models were used to estimate the hazard ratio (HR) of postoperative mortality.

Result

A total of 36380 eligible patients were included. Of these, 248(0.7%) had liver cirrhosis and 70% had compensated disease. The proportion undergoing a colectomy who had a diagnosis of cirrhosis increased from 0.40% in 2001 to 1.07% in 2017 (χ2(16, N = 36380)=50.53, P &lt; 0.0001).

Following elective colectomy, 90-day case fatality was 4% in non-cirrhotics , 7% in compensated cirrhotics and 10% in decompensated cirrhotics. Following emergency colectomy 90-day case fatality was higher, it was 16% in non-cirrhotics, 35% in compensated cirrhotics and 41% in decompensated cirrhotics. This corresponded to an adjusted 2-fold (HR 2.57(95% CI 1.75–3.76)) and 3-fold (3.43(95% CI 2.02–5.83)) increased mortality rate in compensated and decompensated cirrhotics respectively compared to non-cirrhotics following emergency colectomy.

Conclusion

Over the study period, the proportion of patients undergoing colectomy who had liver cirrhosis increased to 1 in every 100 colectomies. The 90-day case fatality rates were high in all patients with cirrhosis in both emergency and elective settings but the greatest mortality risk was seen in those with decompensation following emergency surgery.

Take-home Message

1 in 100 colectomy procedures are in patients with cirrhosis. These cirrhotic patients have a very high risk of postoperative mortality, especially, emergency colectomy in patients with decompensated cirrhosis.

842 Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Extrahepatic Abdominal Surgery: A Systematic Review

Introduction

Perioperative bleeding is a major risk during and after surgery, which can result in increased mortality and morbidity. Tranexamic acid (TXA), in the setting of trauma, minimises perioperative bleeding and its associated risks. However, there is a lack of evidence of its use in elective abdominal surgery. This meta-analysis of randomised controlled trials (RCTs) evaluated the effectiveness and safety of TXA in elective extrahepatic abdominal surgery.

Method

A comprehensive search of PubMed, Embase, and Clinicaltrial.gov databases was undertaken to identify RCTs from January 1947 to May 2020. The primary outcomes of intraoperative blood loss, and the secondary outcomes of need for perioperative blood transfusion, thromboembolic events, and mortality were extracted from included studies. Quantitative pooling of data was based on the random effects model.

Results

Nineteen studies reporting on 2205 patients were included. TXA reduced intraoperative blood loss (weighted mean difference (WMD) -188.35mL; 95% CI -254.65 to -121.72) and the need for perioperative blood transfusion (odds ratio (OR) 0.43; 95% CI 0.28 to 0.65). Importantly, TXA had no impact on the incidence of thromboembolic events (OR 0.49; 95% CI 0.18 to 1.35). There were no reported deaths in any of the studies.

Conclusions

TXA reduces intra-operative blood loss without an increase in complications.

616 Preventing Biofilms on BACTIGON® Coated Camstent Urinary Catheters in Patients Undergoing Elective Colorectal Surgery: A Single Centre Pilot Study

Introduction

Catheter associated urinary tract infections account for 40% of hospital acquired infections. They are associated with biofilms consisting of bacterial cells enmeshed in a self-generated extracellular matrix adhering to catheter surfaces. We have developed a novel polymer family that, coated onto urinary catheters, creates a “non-stick” surface preventing biofilm development.

Method

Prospective cohort of elective colorectal patients recruited pre-operatively, received a standard silicone (SS) or Camstent (BACTIGON®) coated urinary catheter. After removal, catheters were cut longitudinally into 3 segments. Biomass and biomineralisation were analysed using confocal fluorescence microscopy. Data were normalised by square rooting the catheter indwelling duration. Environmental scanning electron microscopy and energy dispersive x-ray spectroscopy was performed.

Results

Of 40 patients, 20 each received a SS or coated catheter. Between SS and coated catheters, average indwelling duration was similar and biofilm biomass was 32.068µg/cm2 (95%CI ±21.950) vs. 1.948µg/cm2 (95%CI ±2.595) (P = 0.0111). Confocal microscopy suggested a 93.93% reduction in biofilm biomass on coated catheters. Mineral compositions were different with biofilm and struvite/apatite on SS and calcium oxalate, endogenously derived, on coated catheters.

Conclusions

Inert BACTIGON® coated catheters appear superior at preventing biofilm formation than SS catheters. Clinical trials are needed to determine the clinical and health economic benefit of this intervention.

664 The ICON Trauma Study: The Impact of the COVID-19 Lockdown on Major Trauma Workload in the UK

Introduction

Anecdotal evidence suggest a direct impact of the SARS-COV-2-pandemic on presentation and severity of major trauma.

Method

This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020 to 18/05/2020) to a historical cohort admitted during a similar time period in 2019 (11/03/2019 to 20/05/2019). Demographic differences, injury method and severity were compared using Fisher’s and Chi-squared tests. Multivariable logistic regression examined the associated factors predicting 30-day mortality.

Results

Of 642 patients, 405 and 237 were in the 2019 and 2020 cohorts respectively. 1.69%(4/237) of the 2020 cohort tested SARS-CoV-2 positive. There was a 41.5% decrease in trauma admissions in 2020. The 2020 cohort was older (median 46 vs.40 years), more comorbid and frailer (p < 0.0015). There was a significant difference in injury method with a decrease in vehicle related trauma, but an increase in falls. There was a 2-fold increased risk of mortality in the 2020 cohort that in adjusted models, was explained by higher injury severity and frailty. Positive SARS-CoV-2 status was not associated with increased mortality on multivariable analysis.

Conclusions

Patients admitted during the SARS-CoV-2-pandemic were older, frailer, more co-morbid and had an increased risk of mortality.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study

Background

The management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease.

Methods

Patients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission.

Results

In total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation.

Conclusion

Non-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.

Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis

BACKGROUND

Perioperative bleeding is associated with increased morbidity and mortality in patients undergoing elective abdominal surgery. The antifibrinolytic agent tranexamic acid (TXA) has been shown to reduce perioperative bleeding and mortality risk in patients with traumatic injuries, but there is a lack of evidence for its use in elective abdominal and pelvic surgery. This meta-analysis of RCTs evaluated the effectiveness and safety of TXA in elective extrahepatic abdominopelvic surgery.

METHODS

PubMed, Embase, and ClinicalTrial.gov databases were searched to identify relevant RCTs from January 1947 to May 2020. The primary outcome, intraoperative blood loss, and secondary outcomes, need for perioperative blood transfusion, units of blood transfused, thromboembolic events, and mortality, were extracted from included studies. Quantitative pooling of data was based on a random-effects model.

RESULTS

Some 19 studies reporting on 2205 patients who underwent abdominal, pelvic, gynaecological or urological surgery were included. TXA reduced intraoperative blood loss (mean difference -188.35 (95 per cent c.i. -254.98 to -121.72) ml) and the need for perioperative blood transfusion (odds ratio (OR) 0.43, 95 per cent c.i. 0.28 to 0.65). TXA had no impact on the incidence of thromboembolic events (OR 0.49, 0.18 to 1.35). No adverse drug reactions or in-hospital deaths were reported.

CONCLUSION

TXA reduces intraoperative blood loss during elective extrahepatic abdominal and pelvic surgery without an increase in complications.

The Use of Prophylactic Somatostatin Therapy Following Pancreaticoduodenectomy: A Meta-analysis of Randomised Controlled Trials

BACKGROUND

Prophylactic administration of somatostatin analogues (SA) to reduce the incidence of post-operative pancreatic fistula (POPF) remains contentious. This meta-analysis evaluated its impact on outcomes following pancreaticoduodenectomy (PD).

METHODS

The EMBASE, MEDLINE and Cochrane databases were searched for randomised controlled trials (RCTs) investigating prophylactic SA following PD. Comparative effects were summarised as odds ratio and weighted mean difference based on an intention to treat. Quantitative pooling of the effect sizes was derived using the random-effects model.

MAIN RESULTS

Twelve RCTs were included involving 1615 patients [SA-treated group (n = 820) and control group (n = 795)]. The SA used included somatostatin-14, pasireotide, vapreotide and octreotide. Pooling of the data showed no significant benefit of its use for the primary outcome measure of all grades of POPF, odds ratio (OR) 0.73 [95% confidence interval (CI), 0.51-1.05, p = 0.09] and clinically relevant POPF, OR 0.48 [95% CI, 0.22-1.06, p = 0.07]. There were no benefits in the secondary outcome measures of delayed gastric emptying, OR 0.98 [95% CI, 0.57-1.69, p = 0.94]; infected abdominal collections, OR 0.80 [95% CI, 0.44-1.43, p = 0.80]; reoperation rates, OR 1.24 [95% CI, 0.73-2.13, p = 0.42]; duration of hospital stay, - 0.23 [95% CI - .59 to 1.13, p = 0.74]; and mortality, 1.78 [95% CI, 0.94-3.39, p = 0.08].

CONCLUSION

SA did not improve the post-operative outcomes following PD, including reducing the incidence of POPF. The routine administration of SA cannot be recommended following PD.

Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis

BACKGROUND

Gallstones account for 30-50 per cent of all presentations of acute pancreatitis. While the management of acute pancreatitis is usually supportive, definitive treatment of gallstone pancreatitis is cholecystectomy. Guidelines from the British Society of Gastroenterology suggest definitive treatment on index admission or within 2 weeks of discharge, whereas joint recommendations from the International Association of Pancreatology and the American Pancreatic Association recommend definitive treatment on index admission. Evidence suggests that uptake of these guidelines is low.

METHODS

Embase, MEDLINE and Cochrane databases were searched for RCTs investigating early versus delayed cholecystectomy in patients with a confirmed diagnosis of mild gallstone pancreatitis. The pooled synthesis was undertaken using a random-effects meta-analysis of the primary outcome of recurrent biliary complications causing hospital readmission. Secondary outcomes included intraoperative and postoperative complications, and total length of hospital stay (LOS). All analyses were performed using RevMan5 software.

RESULTS

Five RCTs were identified, which included 629 patients (318 in the early cholecystectomy (EC) group and 311 in the delayed cholecystectomy (DC) group). Recurrent biliary events that required readmission were reduced in patients undergoing EC compared with the number in patients having DC (odds ratio (OR) 0·17, 95 per cent c.i. 0·09 to 0·33). There was no difference in the rate of intraoperative (OR 0·58, 0·17 to 1·92) or postoperative (OR 0·78, 0·38 to 1·62) complications.

CONCLUSION

EC following mild gallstone pancreatitis does not increase the risk of intraoperative or postoperative complications, but reduces the readmission rate for recurrent biliary complications.

Outcome of indeterminate liver lesions on computed tomography in patients with colorectal cancer

Introduction The aim of this study was to determinate the outcome of indeterminate liver lesions on computed tomography (CT) in patients with a background history of colorectal cancer (CRC) and to identify clinicopathological variables associated with malignancy in these lesions. A secondary aim was to devise a management algorithm for such patients. Methods Patients referred to our institution with indeterminate liver lesions on CT with a background history of CRC between January 2012 and December 2014 were included in the study. Clinicopathological factors, surveillance period and histological findings were analysed. Results Fifty-six patients with indeterminate liver lesions were identified. Fifty-three (94.6%) of these required further imaging (magnetic resonance imaging [MRI; n=50] and positron emission tomography combined with CT [n=3]). For the patients who had MRI, the underlying diagnosis was benign in 19 and colorectal liver metastasis (CRLM) in 8 while 23 patients and an indeterminate lesion. In cases that remained indeterminate following MRI, liver resection was performed in 2 patients for a high suspicion of CRLM while the 21 remaining patients underwent interval surveillance (median: 9 months, range: 3-52 months). Of these 21 patients, 14 had benign lesions while CRLM was noted in 6 patients and an incidental hepatocellular carcinoma in a single patient. Age ≥65 years was the only statistically significant clinicopathological factor in predicting an underlying malignancy in patients with indeterminate liver lesions on CT. Conclusions Over a third of the patients diagnosed with indeterminate liver lesions on CT subsequently showed evidence of CRLM. These indeterminate lesions are more likely to be malignant in patients aged ≥65 years.