Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.

Left hepatic trisectionectomy for hepatobiliary malignancies: Its' role and outcomes. A retrospective cohort study

Background

Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear.

Materials and methods

All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database.

Results

Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively.

Conclusion

This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

•

LHT is an extended resection reported to have higher incidences of morbidity and mortality compared with less extensive hepatic resections.

•

This procedure is useful for the surgical management of patients with hepatic lesions that were previously considered unresectable.

•

We report favourable outcomes following LHT at our institution compared with less extensive hepatic resections.

•

An initial post-operative lactate of >1.5 mmol/L was associated with an increased risk of developing post-operative complications (p = 0.035).

Acute necrotising pancreatitis - early management in the district general hospital and tertiary hepato-pancreatico-biliary unit

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.

Primary hepatic solitary fibrous tumor with histologically benign and malignant areas

Extrapleural solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm, presenting most commonly in the intrathoracic sites but which has been reported at numerous extrathoracic locations. The majority of intra-thoracic SFTs are benign, but 10%-15% behave aggressively. We report a case of primary hepatic SFT with histologically benign and malignant areas. A 65-year-old man underwent an abdominal CT scan following a cerebrovascular accident, which demonstrated a sharply demarcated large liver mass with a heterogenous enhancing area and occupying most of the left lobe of the liver. Histological examination following a hemihepatectomy showed an SFT with morphological patterns ranging from benign to malignant areas, including pleomorphism, increased cellularity, herringbone pattern, necrosis and a raised mitotic count. On review of the literature, only an occasional case report with malignant areas in a hepatic SFT was identified. This case highlights that SFT should be included in the differential diagnosis of a hepatic spindle cell lesion, and that on rare occasions, malignant areas can occur in this already uncommon neoplasm.

Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy

INTRODUCTION

Afferent loop syndrome (ALS) is a recognised complication of foregut surgery caused by mechanical obstruction at the gastrojejunostomy anastomosis itself or at a point nearby. Acute ALS has only been reported following pancreaticoduodenectomy (PD) after several years due to recurrence of malignancy at the anastomotic site. We report five cases of acute ALS in the first postoperative week.

METHODS

The presentation, clinical findings and successful management of the 5 patients with ALS were obtained from a prospectively collected database of 300 PDs. All five patients with early acute ALS presented with signs and symptoms of a bile leak. Since the fifth patient, the surgical technique has been modified with the creation of a larger window in the transverse mesocolon and a Braun enteroenterostomy.

RESULTS

There have been no further incidents of ALS since the adoption of these modifications to the standard technique of PD and there has also been a reduction in postoperative bile leaks (6.4% vs 3.6%, p=0.416).

CONCLUSIONS

Acute ALS is a rare but important complication in the immediate postoperative period following PD and causes disruption to adjacent anastomoses, resulting in a bile leak. A prophylactic Braun anastomosis and wide mesocolic window may prevent this complication and subsequent deterioration.

Liver metastases from esophageal carcinoma: is there a role for surgical resection?

Esophageal cancer recurrence rates after esophagectomy are high, and locally recurrent or distant metastatic disease has poor prognosis. Management is limited to palliative chemotherapy and symptomatic interventions. We report our experience of four patients who have undergone successful liver resection for metastases from esophageal cancer. All underwent esophagectomy and were referred to our unit with metastatic recurrent liver disease, two with solitary metastases and two with multi-focal disease. The patients underwent multidisciplinary assessment and proceeded to a course of neoadjuvant chemotherapy followed by open or laparoscopic liver resection. Three patients were male, and the mean age was 57.5 (range 44-71) years. Response to chemotherapy ranged from partial to complete response. Following liver resection, two patients developed recurrent disease at 5 and 15 months, and both had disease-specific mortality at 10 and 21 months, respectively. The other two patients remain disease free at 22 and 92 months. Recurrent metastatic esophageal cancer continues to have a poor prognosis, and the majority of patients with liver involvement will not be candidates for hepatic resection. However, this series suggests that in selected patients, liver resection of metastases from esophageal cancer combined with neoadjuvant and adjuvant chemotherapy is feasible, but further research is required to determine whether this can offer a survival advantage.

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy

INTRODUCTION

Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN).

METHODS

Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male.

RESULTS

The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%).

CONCLUSIONS

Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.

An unusual complication of PEG feeding after pancreatico-gastrostomy

CONTEXT

We describe a late complication of the pancreatico-gastrostomy (PG) anastomosis following pancreatico-duodenectomy (PD).

CASE REPORT

A percutaneous endoscopic gastrostomy (PEG) feeding tube was inserted many months post-operatively. In this patient activated pancreatic enzymes eroded the gastrostomy tract, resulting in pain, recurrent infection and eventual removal of the gastrostomy tube.

CONCLUSIONS

Where surgical insertion of a feeding jejunostomy is not viable or deemed too high risk after Whipple or PPPD, we recommend careful consideration of PEG tube insertion in patients with PG reconstruction. If a PEG is used the prophylactic use of Lanreotide is recommended.

Delayed bile leak with avastin after liver resection for metastatic colorectal cancer

Chemotherapy for metastatic colorectal cancer is constantly advancing. Its use in the adjuvant and neoadjuvant setting is also increasing. However, while long-term survival is improving, clinicians must be aware of the possible adverse events that can occur when treating with adjuvant chemotherapy and liver resection. We present a case of a life-threatening delayed bile leak following a liver resection for metastatic colorectal cancer in association with adjuvant treatment with bevacizumab. A 53-year-old man was treated with neoadjuvant bevacizumab followed by liver resection for metastatic colorectal cancer. He made an uneventful recovery. Forty-three days post-surgery he received bevacizumab and developed acute life-threatening bile leaks from the cut surface of the liver. He spent a total of 65 days in hospital, and required ERCP repeatedly and eventually had a repeat liver resection to resolve the bile leak. This case reports a possible association between bevacizumab and a life threatening delayed bile leak following liver resection.

The value of intraoperative ultrasound and preoperative imaging, individually and in combination, in liver resection for metastatic colorectal cancer

INTRODUCTION

Liver resection is proved to offer potential long-term survival for colorectal liver metastases (CRLM). Accurate radiological assessment is vital to enable an appropriate surgical approach. The role of intraoperative ultrasound (IOUS) has been controversial. This study was designed to analyse the accuracy of IOUS compared with that of preoperative imaging (POI) in these patients.

MATERIALS AND METHODS

A prospective analysis of 51 consecutive patients who underwent liver resection for CRLM was undertaken. The accuracy of POI and IOUS were correlated and compared with histopathological analysis. Statistical analyses included t-tests, to compare continuous variables, and chi-square and Fisher's exact tests to compare categorical variables. p<0.05 was considered significant

RESULTS

POI correlated with histology in 35 patients (68.6%). The sensitivity and specificity were 82.4% and 86.3% respectively. IOUS correlated with histology in 31 (60.8%) patients. The sensitivity and specificity were 84.3% and 76.5% respectively. There was no difference in accuracy between modalities. The accuracy of POI combined with IOUS correlated with histology in 40 patients (78.4%). The sensitivity and specificity were 88.2% and 84.3% respectively. The accuracy of combined modalities was significantly greater than IOUS or POI alone.

CONCLUSIONS

POI combined with IOUS may significantly increase the diagnostic accuracy of patients undergoing liver resection for CRLM.

Liver resection for colorectal cancer metastases involving the caudate lobe

BACKGROUND

Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer-involved resection margins of over 50 per cent being reported following caudate lobe resection.

METHODS

Outcomes of consecutive liver resections for colorectal metastases involving the caudate lobe between 1996 and 2009 were reviewed retrospectively, and compared with those after liver surgery without caudate resection.

RESULTS

Twenty-five patients underwent caudate and 432 non-caudate liver resection. Caudate resection was commonly performed as part of extended resection. There were no differences in operative complications (24 versus 21·1 per cent; P = 0·727) or blood loss (median 300 versus 250 ml; P = 0·234). The operating time was longer for caudate resection (median 283 versus 227 min; P = 0·024). Tumour size was larger in the caudate group (median 40 versus 27 mm; P = 0·018). Resection margins were smaller when the caudate lobe was involved by tumour, than in resections including tumour-free caudate or non-caudate resection; however, there was no difference in the proportion of completely excised tumours between caudate and non-caudate resections (96 versus 96·1 per cent; P = 0·990). One-year overall survival rates were 90 and 89·3 per cent respectively (P = 0·960), with 1-year recurrence-free survival rates of 62 and 71·2 per cent (P = 0·340).

CONCLUSION

Caudate lobe surgery for colorectal cancer liver metastases does not increase the incidence of resection margin involvement, although when the caudate lobe contains metastases the margins are significantly closer than in other resections.

Early and Long-Term Outcomes of Patients Undergoing Liver Resection and Diaphragm Excision for Advanced Colorectal Liver Metastases

INTRODUCTION

At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However, there are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients.

PATIENTS AND METHODS

A total of 285 consecutive liver resections were performed over a 10-year period. Of these, 258 had liver resections alone and 27 underwent liver resection and simultaneous diaphragm excision. Data were collected prospectively and analysed retrospectively. Pre-operative assessment was standardised. The outcomes between the two groups were compared.

RESULT

There was no difference in age, hospital stay or intra-operative blood loss. The diaphragm was histologically involved in four out of 27 resections. As a result, the cancer involved resection margin incidence was greater in the liver resection and diaphragm excision group (14.8% versus 3.9%; P = 0.12). The median tumour size was also different between the two groups (60 mm versus 30 mm; P = 0.001). The liver and diaphragm resection group had a greater peri-operative complication rate (44.4% versus 21.3%; P = 0.02) and mortality (7.4% versus 1.6%; P = 0.25). Overall and disease-free survival was significantly worse in the group who underwent simultaneous diaphragm excision and liver resection (P = 0.04 and P = 0.005, respectively). Diaphragm invasion was found to be an independent predictor of poor overall outcome (P = 0.02).

CONCLUSION

Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.

Operative mortality, blood loss and the use of Pringle manoeuvres in 526 consecutive liver resections

INTRODUCTION

Centres with high volumes of high-risk surgery have significantly better outcomes than low-volume centres for pancreatic resection, oesophagectomy and pelvic exenteration. However, this has not to date been conclusively demonstrated for hepatic resection. With increased experience, operative practice can change. The use of the Pringle manoeuvre reduced substantially over a 12-year period in a single centre as it was felt anecdotally that its use increased the incidence of hepatic insufficiency and operative mortality. This study was designed to review 12 years of experience in a single hepatobiliary centre.

PATIENTS AND METHODS

Data regarding 526 consecutive liver resections were prospectively recorded and retrospectively analysed in a high-volume referral unit over a 12-year period. Patients' demographics, operative mortality and morbidity were analysed on an annual basis.

RESULTS

Overall peri-operative mortality was 1.9%. Operative mortality in the first 6 years compared to the latter 6 years was 4.1% and 1.2%, respectively (P = 0.13). The morbidity rate was 26.8% and 20.3% in the first and second halves of the study, respectively (P = 0.15). With increased experience, intra-operative blood loss and patients receiving blood transfusions decreased (P = 0.047 and 0.03, respectively) while the number of intra-operative Pringle manoeuvres also decreased (P < 0.0001). Hospital stay decreased significantly over the 12 years (P = 0.049).

CONCLUSIONS

High-volume centres are the safest environment for hepatic resection. With increased experience, it may be possible to reduce the intra-operative use of the Pringle manoeuvre without increasing the intra-operative blood loss. This may be associated with a decrease in hepatic insufficiency and peri-operative mortality.

Early and long-term outcomes of patients undergoing liver resection and diaphragm excision for advanced colorectal liver metastases

INTRODUCTION

At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However, there are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients.

PATIENTS AND METHODS

A total of 285 consecutive liver resections were performed over a 10-year period. Of these, 258 had liver resections alone and 27 underwent liver resection and simultaneous diaphragm excision. Data were collected prospectively and analysed retrospectively. Pre-operative assessment was standardised. The outcomes between the two groups were compared.

RESULTS

There was no difference in age, hospital stay or intra-operative blood loss. The diaphragm was histologically involved in four out of 27 resections. As a result, the cancer involved resection margin incidence was greater in the liver resection and diaphragm excision group (14.8% versus 3.9%; P = 0.12). The median tumour size was also different between the two groups (60 mm versus 30 mm; P = 0.001). The liver and diaphragm resection group had a greater peri-operative complication rate (44.4% versus 21.3%; P = 0.02) and mortality (7.4% versus 1.6%; P = 0.25). Overall and disease-free survival was significantly worse in the group who underwent simultaneous diaphragm excision and liver resection (P = 0.04 and P = 0.005, respectively). Diaphragm invasion was found to be an independent predictor of poor overall outcome (P = 0.02).

CONCLUSIONS

Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.

'Close shave' in liver resection for colorectal liver metastases

INTRODUCTION

The optimal size of clear liver resection margin width in patients with colorectal liver metastases (CRLM) remains controversial. The aim of this study was to investigate the effects of margin width on long-term survival after liver resection for CRLM with a policy of standard neo-adjuvant chemotherapy.

METHODS

Consecutive patients (n=238) who underwent liver resection for CRLM were included over a ten-year period. All patients with synchronous or early (<2 years) metachronous tumours were treated with neo-adjuvant chemotherapy. Data were recorded prospectively.

RESULTS

Overall survival of the cohort at 1, 3 and 5 years were 90.3%, 68.1% and 56.1% respectively. The incidence of cancer involved resection margins (CIRM) was 5.8%. Patients with macroscopically involved resection margins had a poorer overall survival than those with microscopically involved margins (p=0.04). Involved resection margins had a poorer overall survival (p=0.002) than patients with clear margins. Width of clear resection margin did not affect long-term survival.

CONCLUSION

CIRM independently predicts poor outcome in patients with CRLM. Clear margin width does not affect survival. A standard policy of neo-adjuvant chemotherapy may be associated with a low incidence of CIRM and improved long-term outcome of sub-centimetre margin widths, resembling those with >1cm resection margins.

Early postoperative outcomes following hepatic resection for benign liver disease in 79 consecutive patients

BACKGROUND

Liver resection is an accepted treatment modality for malignant disease of the liver. However, because of its potential morbidity and mortality, the practice of liver resection in benign disease is more controversial. This study was designed to assess the early outcomes of 79 consecutive liver resections for benign disease over a 12-year period and compare these with early outcomes of 390 consecutive liver resections for metastatic colorectal cancer (MCRC) during the same period.

METHODS

Consecutive liver resections were carried out in a single hepatopancreatobiliary (HPB) centre between 1996 and 2008. Patient demographics and early outcomes were recorded. Statistical analyses were performed using spss (Version 15). P < 0.05 was considered to be significant.

RESULTS

There was no difference in median age between the benign group vs. the MCRC group (P = 0.181). However, there was a significant trend towards a lower ASA grade in the benign group (P < 0.001). There was no difference in median blood loss (P = 0.139) or hospital stay (P = 0.262). Morbidity rates were 8.9% in the benign group and 20.5% in the MCRC group (P = 0.002). The rate of serious complications was 1.3% in the benign group compared with 4.4% in the MCRC group (P = 0.041). There were no postoperative deaths in the benign group and eight (2%) in the MCRC group (P = 0.004).

CONCLUSIONS

Liver resection for benign liver tumours can be undertaken with a mortality rate approaching zero and minimal morbidity in specialist HPB units.

Feeding patients following pancreaticoduodenectomy: a UK national survey

INTRODUCTION

Providing nutrition for patients following pancreaticoduodenectomy (PD) is vital but can be challenging. Due to the lack of UK national guidelines for the provision of nutrition and nutritional pre-operative assessment regarding PD, a national survey was conducted.

PATIENTS AND METHODS

A questionnaire was sent to the Department of Nutrition and Dietetics at each of the 31 specialist pancreatic centres listed with the Pancreatic Society of Great Britain and Ireland. Questions were asked regarding the nutritional assessment and treatment of patients undergoing classical PD and pylorus-preserving PD (PPPD) resections.

RESULTS

Twenty-two centres responded to the questionnaire. With regard to PD and PPPD, 82% routinely feed patients following resection, 32% have a regimen for staring feeds, 18% carry out pre-operative nutritional assessment, five centres have funding for an hepatobiliary dietition, and only four centres have a specialist hepatobiliary dietition employed. There was no consensus regarding the type or route of feeding, and at least one centre reported using parenteral nutrition exclusively.

CONCLUSIONS

Very few centres in the UK have funding for a hepatobiliary dietition. Hence pre-operative nutritional assessment in patients undergoing PD and PPPD does not receive much input. Although the importance of postoperative feeding in these patients is appreciated in all major units, there is no consensus with regards to feeding regimens. The authors hope this observational study will address these issues with this important message and stimulate further study in this area.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Reduced adhesion formation following laparoscopic versus open colorectal surgery

BACKGROUND

Adhesion formation is common after abdominal surgery. This study aimed to compare the extent of adhesion formation following laparoscopic and open colorectal surgery.

METHODS

An observational study was undertaken to identify adhesions in patients undergoing laparoscopy after previous laparoscopic or open colectomy. Adhesions were scored according to a system validated for interobserver (median kappa = 0.80) and intraobserver (kappa = 0.82) agreement. The primary endpoint was the overall adhesion score (0-10); a secondary endpoint was the adhesion score at the main incision site (0-6).

RESULTS

Forty-six patients were recruited (13 laparoscopic and 33 open colectomy). In most patients (n = 29), laparoscopy was performed for tumour staging before liver resection. The median (interquartile range) overall adhesion score was 7 (5-8) in the open group and 0 (0-3) in the laparoscopic group (P < 0.001). A similar difference was found for the main incision score: 6 (4-6) versus 0 (0-0) (P < 0.001).

CONCLUSION

There may be a reduction in adhesion formation following laparoscopic compared with open colectomy, although the small sample size limits this conclusion.

A 10-year study of outcome following hepatic resection for colorectal liver metastases - The effect of evaluation in a multidisciplinary team setting

AIMS

Colorectal carcinoma is the second most common cause of cancer death in the western world and nearly 50% of patients develop liver metastases. Many cancers are managed via a multidisciplinary team process. This study compares the long term outcome of patients with metastatic colorectal cancer referred via a multidisciplinary team including a liver surgeon (MDT) with those referred directly to a specialist hepatobiliary unit.

PATIENTS AND METHOD

This is a prospective study of 331 consecutive referrals made to a specialist hepatobiliary unit over ten years out of which 108 patients were referred via a colorectal MDT which included a liver surgeon and 223 were directly referred via colorectal MDTs without a liver surgeon. Pre-operative assessment and management were standardised and short and long term data were recorded.

RESULTS

Patients referred via the MDT had 1-, 3- and 5-year survival rates of 89.6%, 67.5% and 49.9% respectively and 1-, 3- and 5-year disease-free survival of 65.4%, 31% and 27.2% respectively. Patients referred directly had 1-, 3- and 5-year survival rates of 90.3%, 54.1% and 43.3% respectively and 1-, 3- and 5-year disease-free survival rates of 70.3%, 37.6% and 27.9% respectively. The difference in overall survival was significant (P=0.0001), although the difference in disease-free survival was not (P=0.21).

CONCLUSION

Assessing, managing and referring patients with metastatic colorectal cancer via a multidisciplinary team including a liver surgeon is associated with improved overall survival.

A comparison of right and extended right hepatectomy with all other hepatic resections for colorectal liver metastases: a ten-year study

AIMS

Colorectal liver metastases are treated by a combination of adjuvant chemotherapy followed by liver resection. In this study we compared all major right-sided resections with left or parenchymal sparing resections.

METHODS

Consecutive patients (n=283) who had successful hepatic resections for colorectal metastases from September 1996 to November 2006 were prospectively studied. Early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardised for all.

RESULTS

The 1-, 3- and 5-year overall survival rates in the RH group were 84.1%, 54.3% and 38.9%, respectively. The 1-, 3- and 5-year overall survival rates in the AOLR group were 95.4%, 65.9% and 53.3%, respectively. The difference was statistically significant (p=0.03). The 1-, 3- and 5-year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5%, respectively and 68.4%, 34.91% and 34.91%, respectively in the AOLR group (p=0.46). Operative mortality was 3.9% in the RH group and 0.7% in the AOLR group (p=0.04). Morbidity was 31.3% in the RH group and 18% in the AOLR group.

CONCLUSION

Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

Jejunal perforation in gallstone ileus - a case series

Introduction

Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.

Case presentations

Case 1

A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.

Case 2

A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.

Conclusion

Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.

Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.

These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.

Debulking hepatectomy for an unusual case of a grade 1 stage 1 granulosa cell tumour of the ovary with late metastases

Granulosa cell tumours of the ovary are rare. They are considered low-grade malignant cancers and infrequently metastasise to the liver. We present our experience of a case with a grade 1, stage 1 granulosa cell tumour of the ovary that systemically recurred 15 years following surgical resection. The patient went on to have a debulking hepatic resection 21 years following initial surgery despite a 6-year-long palliative diagnosis.

A rare case of a retroperitoneal enterogenous cyst with in-situ adenocarcinoma

Background

Retroperitoneal enterogenous cysts are uncommon and adenocarcinoma within such cysts is a rare complication.

Case presentation

We present the third described case of a retroperitoneal enterogenous cyst with adenocarcinomatous changes and only the second reported case whereby the cyst was not arising from any anatomical structure.

Conclusion

This case demonstrates the difficulties in making a diagnosis as well as the importance of a multi-disciplinary approach, and raises further questions regarding post-operative treatment with chemotherapy.

The impact of staging laparoscopy prior to hepatic resection for colorectal metastases

AIMS

To evaluate the role of routine laparoscopy as a staging modality prior to laparotomy and hepatic resection for metastatic colorectal cancer.

METHODS

Prospectively collected data were analysed from a database. In the first half of the series patients underwent selective laparoscopy before proceeding to laparotomy and in the second part of the series laparoscopy was used routinely. Patients undergoing laparotomy directly were analysed in Group 1 and those having laparoscopy before laparotomy in Group 2. The ability of laparoscopy to pick up unresectable and extrahepatic disease, resectability rate and open and close laparotomy rate were recorded.

RESULTS

Of the 284 patients, 74 were in Group 1 (no laparoscopy) and 210 in Group 2 (laparoscopy as standard). The resectability rate was 81% in Group 1 and 87% in Group 2. The open and close laparotomy rate was 19% and 8%, respectively (p=0.025). In Group 2 alone, laparoscopy identified 39% of unresectable disease and prevented an open and close procedure.

CONCLUSIONS

Routine use of staging laparoscopy increases the resectability rate and reduces the inoperability rate in these patients.

Total gastric necrosis due to aberrant arterial anatomy and retrograde blood flow in the gastroduodenal artery: a complication following pancreaticoduodenectomy

Patients with coeliac artery occlusion often remain asymptomatic due to the rich collateral blood supply (pancreaticoduodenal arcades) from the superior mesenteric artery. However, division of the gastroduodenal artery (GDA) during pancreaticoduodenectomy may result in compromised blood supply to the liver, stomach and spleen. Postoperative complications associated with this condition are rarely reported in the literature. We report two cases of coeliac artery occlusion encountered during pancreaticoduodenectomy, one of which was complicated by hepatic ischaemia and total gastric infarction postoperatively. Based on our experience and review of the literature, a management algorithm for coeliac artery stenosis encountered during pancreaticoduodenectomy is proposed.

Hepatic resection for breast cancer metastases

INTRODUCTION

Hepatic resection is an established modality of treatment for colorectal cancer metastases. Resection of breast cancer liver metastases remains controversial, but has been shown to be an effective treatment in selected cases. This study reports the outcome of 8 patients with liver metastases from breast cancer.

PATIENTS & METHODS

8 patients with liver metastases from previously treated breast cancer were referred for hepatic resection between September 1996 and December 2002. Six were eligible for liver resection. The mean age was 45.8 years. The resections performed included 1 segmentectomy and 5 hemihepatectomies of which one was an extended hemihepatectomy. One patient had a repeat hepatectomy 44 months after the first resection.

RESULTS

There were no postoperative deaths or major morbidity. The resectability rate was 75%. Follow-up periods range from 6 to 70 months with a median survival of 31 months following resection. There have been 2 deaths, one died of recurrence in the residual liver at 6 months and one died disease-free from a stroke. Of the remaining 4 patients, 1 has had a further liver resection at 44 months following which she is alive and 'disease-free' at 70 months. The one patient with peritoneal recurrence is alive 49 months after her liver resection with 2 patients remaining disease-free.

CONCLUSION

Hepatic resection for breast cancer liver metastases is a safe procedure with low morbidity and mortality.

The measurement of liver resection margins

BACKGROUND

All tissue shrinks to some degree when placed in formalin fixative solution. The degree of shrinkage of liver tissue has particular relevance to the measurement of resection margins, as the current recommendation is that the surgeon should aim to achieve a resection margin of at least 1 cm. We were unable to find any published data concerning shrinkage of liver tissue in formalin. The aim of this study was therefore to quantify the shrinkage of liver specimens in the fixation process.

METHODS

Distances of 10, 30 and 50 mm were measured and marked on 18 fresh liver specimens. The specimens were then fixed in 10% formalin solution for 24 h, and the distances were re-measured to assess shrinkage.

RESULTS

The observed shrinkage at all three distances was <10% after 24 h in formalin. The degree of shrinkage was statistically significant.

CONCLUSION

Although the degree of shrinkage is small, it may be important when considering resection margins of the order of 1 cm and should therefore be taken into account.

Long-term survival with stage IV poorly differentiated pancreatic adenocarcinoma

BACKGROUND

Metastatic poorly differentiated adenocarcinoma of the pancreas has a poor outcome despite the use of various chemotherapy regimes.

CASE OUTLINE

A 57-year-old woman presented with a 3-month history of generalised abdominal pain associated with weight loss. Computed tomography (CT) showed a large tumour in the head and body of pancreas, and needle biopsy confirmed a poorly differentiated adenocarcinoma. Laparoscopy revealed liver metastases in both lobes, again histologically shown to be poorly differentiated adenocarcinoma. Six cycles of cisplatin, epirubicin and infusional 5-fluorouracil were given. Five years later the patient remains completely well. Repeat CT scans show a complete radiological response.

DISCUSSION

Previous studies using numerous chemotherapy regimes have not significantly altered the outcome of pancreatic cancer. To the best of our knowledge this is the longest surviving case of a patient with advanced metastatic adenocarcinoma (stage IV) of the pancreas treated with chemotherapy.

A review of techniques for liver resection

BACKGROUND

There has been a significant increase in the number of hepatic resections performed. The aim of this review was to assess available techniques for liver resection and their application.

METHODS

A literature review was performed based on a Medline search to identify articles on liver resection. Keywords included liver resection, liver neoplasm, cancer, colorectal metastases and hepatocellular carcinoma.

RESULTS

Improved understanding of the segmental anatomy of the liver has resulted in the evolution of liver resection. The development of new approaches to the biliovascular tree, combined with clamping to produce ischaemic demarcation, has been important in demonstrating segmental boundaries for resection. The combination of methods of vascular control such as the Pringle manoeuvre and techniques of parenchymal resection such as ultrasonic dissection allows hepatic resection with minimal blood loss and morbidity.

CONCLUSIONS

Application of refined techniques for liver resection by specialised units allows liver resection to be performed on both normal and cirrhotic livers with low morbidity and mortality.

Giant sigmoid diverticulum causing colonic and urinary obstruction

Diverticulosis of the colon is a fairly common disease, but a solitary giant diverticulum is relatively rare. This case presented with symptoms of urinary and bowel obstruction.

Regional pancreatectomy and transverse colectomy with mesenteric vascular reconstruction for inflammatory pseudotumour of the head of pancreas and mesenteric root

BACKGROUND

Inflammatory myofibroblastic pseudotumour is a rare pancreatic lesion.

CASE OUTLINE

A 32-year-old woman with such a tumour was treated by a radical operation comprising proximal pancreatic-duodenectomy (Whipple Procedure) and transverse colectomy with resection and reconstruction of the superior mesenteric artery and vein. She remains well 6 years later.

DISCUSSION

The importance of aggressive surgical clearance rather than chemotherapy is highlighted in the management of patients with these unusual tumours.

Anatomical variations of the extrahepatic biliary tree: review of the world literature

The anatomy facing a surgeon during cholecystectomy involves complex relationships between the hepatic artery, extrahepatic biliary tree, and gallbladder. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. Equally important, however, is an understanding of congenital variation of biliary and vascular anatomy, as the literature abounds with reports of specific anatomical variations, and their operative implications. This article reviews the world literature on congenital variation of extrahepatic biliary anatomy.

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