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Introduction The liver is a frequent site for tumour metastases, and surgery for colorectal liver metastases (CRLM) is well established, with survival rates accepted to be 50% in 5 years. However, surgery for NCRNNE has been approached with caution. We aimed to report the outcomes of surgery for NCRNNE in our unit, to determine the patterns of disease presentation, recurrence and survival. Methods We identified 78 patients who had liver resection from NCRCNNE primary tumours from 28 December 1992 to 2 August 2011 using a prospectively maintained database; Breast (N=19), Malignant Melanoma (N=4), Renal (N=10), Anal Squamous Cell Carcinoma (N=5), Lung (N=3), Sarcoma (N=15), GIST (N=13), Squamous-other (cervix, bile duct, oropharynx) (N=6) and Gastric Adenocarcinoma (N=3). The electronic records of all these patients were then retrospectively reviewed. We obtained data on patient demographics, presentation of disease, pathological data, recurrence and survival. Data were analysed using ANOVA and Kaplan–Meier tests. Results The age at diagnosis varied with tumour type; the youngest was sarcoma (46 years) and the oldest gastric (67 years). The progression to detectable liver disease was quickest with Anal Squamous Cell Carcinoma metastases (172 days), which also had a 60% recurrence rate within a mean of 192 days. Malignant Melanomas had a 100% recurrence rate, which occurred at a mean of 321 days. Breast metastases were the least likely to recur (33%) and had a long disease-free period between recurrences (468 days). The largest metastases were seen in sarcomas (67 cm) and the smallest in melanomas (28 cm). There was no significant correlation between size or number of tumours and survival. The 1- 3- and 5-year survival from the time of NCRCNNE metastectomy was 88%, 56% and 47% respectively, compared with 86%, 58% and 46% after CRLM metastectomy. Malignant Melanomas and Anal Squamous Cell Carcinoma had the poorest outcome; 100% mortality at 5 years. Conclusion Liver Resection is an effective treatment for metastases from NCRCNNE tumours in highly selective patients. In the right patient, surgery offers similar survival rates to resection of CRC metastases, but some tumour types do better than others, and a decision to proceed with resection should take into account the histological diagnosis, and an understanding of the behaviour of that tumour type. Competing interests None declared.

Introduction Lymph node status is an important predictor of survival following resection for hilar cholangiocarcinoma (HCCA). Controversies still exist regarding the extent of lymphadenectomy and whether an extended lymph node dissection improves outcome. This study aims to evaluate the prognostic value of the total number of nodes removed and positive lymphnode ratio (LNR) on overall and disease-free survival in patients undergoing resection for HCCA. Methods From 1994 to 2010, 84 HCCA were resected at our Institution. Seventy-eight patients with available data were included in our analysis. Overall survival (OS) and disease-free survival (DFS) were calculated and stratified according to the number of lymph nodes excised and positive LNR at different cut-off levels. Results An average of 13.8 lymph nodes were removed. 45 patients (57.7%) had a positive lymph node status, with a mean of 3.2 involved nodes per patient. 1, 5 and 10-year OS for N+ status was 60%, 10% and 10%, while N- OS was 82%, 41% and 41% (p=0.000). Similarly, 1, 5 and 10-year DFS was worse in the N+ group (71%, 45% and 42%) compared to N- (91%, 65% and 60%) (p=0.045). There was no difference in 1, 5 and 10-year OS (70%, 23%, 20% vs 70%, 23% and 20%, p=0.690) and DFS (78%, 48% and 48% v s 82%, 58% and 58%, p=0.305) when 0.25 (n=23). No difference was found when a cut-off of 15 total excised lymphnodes and LNR of 0.50 was used. Conclusion The overall number of lymphnodes excised and positive LNR did not correlate with overall and DFS in resected HCCA. Larger, prospective studies are necessary to confirm these results. Competing interests None declared.

Introduction Living Donor Liver Transplantation (LDLT) has grown immensely in certain countries over the last few years, whereas in West the growth remains static and low volume. Donor morbidity following LDLT has been reported in the median range of 15%–30% in various studies. One of the limiting factor for the growth of LDLT has been the concerns with morbidity and mortality during a centres initial experience. We report the donor outcome from a small volume centre, so as to assess if there is an impact on volume with donor outcome. Methods Between June 2007 and December 2011, 25 LDLT procedures were carried out in our unit. The criteria for donor selection included age, fitness for surgery and remnant liver volume. Donor demographics, graft type, complications, length of stay and overall survival were extracted. Donor morbidity was assessed objectively using the modified Clavien-Dindo classification. Continuous variables are expressed as mean ± SD. Results The mean donor age was 38.4±11.0 years and donor BMI was 23.9±2.8 kg/cm 2 . Two donors were abandoned on table due to complex arterial and biliary anatomy respectively. The graft type was right lobe (n=12, 52.2%), left lateral lobe (n=10, 43.5%) and left lobe (n=1, 4.3%). The graft weight was 528.5±258.9 g. The morbidity was 21.7% (n=5). There were three Clavien grade II complications (wound infection, urinary infection and unknown sepsis needing antibiotics). One patient needed laparotomy for haemorrhage (Grade IIIb) and another patient had ultrasound guided drainage of subphrenic collection (Grade IIIa). None of our patients had any post-operative blood transfusion. The length of hospital stay was 7.9±2.8 days. At the end of median follow-up of 21.4 months, all our donors were alive, with no long-term morbidity. Conclusion Our experience shows that donor hepatectomy for Living Donor Liver Transplantation is a safe procedure in a small volume unit. Our donor morbidity of 21.7% is comparable or better than most high volume centres across the world. Number of procedures performed by the unit shouldn9t be an hindrance to the introduction of live donor liver programme. Competing interests None declared.

Introduction Obesity levels in the UK have risen over the years. Studies from the US and elsewhere have reported variable outcomes in terms of post liver transplant morbidity, mortality and graft survival in obese liver transplant recipients. There are no such reports from the UK. The aim of this study was to analyse the impact of BMI (Body Mass Index) on outcomes following adult liver transplantation. Methods Data were retrieved from a prospectively maintained institutional database from 1994 to 2009. Patients were stratified into four BMI categories established by the WHO: underweight ( 2 ), normal weight (18.5– 2 ), over weight (>25.0– 2 ) and obese (>30.0 kg/m 2 ). Primary outcome was to evaluate post-operative morbidity and secondary measures were overall patient and graft survival. Categorical variables were analysed by χ 2 , and continuous variables by one-way ANOVA (p Results 1400 adult transplants were identified. 1325 patients had height and weight measurements and were included in the study. The overall morbidity was higher in overweight (71.9%, p Conclusion This is the largest and the only reported UK series on BMI and outcome following liver transplantation. Overweight and obese patients have increased morbidity in terms of septic complications following liver transplantation, with consequent increased length of intensive care and hospital stay. Identifying these patients early and introduction of measures to reduce BMI should be considered to improve outcomes following liver transplantation. Competing interests None declared.

Introduction Non-anatomical resection (NAR) for colorectal liver metastasis (CRLM) has become more common in an attempt to preserve liver parenchyma. Pattern of recurrence (POR) following NAR has been reported previously, but there has been no detail on the hepatic recurrences with respect to previous NAR. We aim to investigate pattern of hepatic recurrence in patients who underwent NAR for CRLM, especially looking at the recurrences in the context of previous resected segment. Methods 1580 CRLM resection were performed in our centre between 1993 and 2010. 591 (37.4%) were NAR and 989 (62.6%) were AR. Patients who underwent simultaneous Anatomical Resection (AR) were excluded (95 out of 591). All NAR were grouped as either unilobar or bilobar metastatectomy and POR studied in relation to previous resected segment. Results 495 NAR were included. There were 291 recurrences (58.7%). 188 were hepatic (37.9%) and 103 extra-hepatic (20.8%). In 11 patients with hepatic recurrence, data were not available for recurrence segment and therefore excluded from POR analysis. The POR following unilobar metastatectomy (n=127): same segment (n=32, 25.2%), same sector (n=9, 7.1%), ipsilateral hemi-liver (n=48, 37.8%), contralateral hemi-liver (n=15, 11.8%) and bilobar (n=23, 18.1%). The POR following bilobar metastatectomy (n=50): same segment (n=1, 2%), hemi-liver with equal number of segments resected previously (n=15, 30%), hemi-liver with lesser involved segments previously (n=7, 14%), hemi-liver with more segment involved previously (n=10, 20.0%) and bilobar (n=17, 34.0%). Conclusion This retrospective study shows that following unilobar CRLM resections, 70.0% recur in the ipsilateral hemi-liver. In bilobar resections, 22.0% recur in the same segment or hemi-liver with previous multiple resections. Our data supports a more aggressive approach for unilobar disease. Further studies need to be done on pattern of recurrences in patients undergoing parenchyma preserving surgery to develop best surgical strategies. Competing interests None declared.

Introduction Colorectal cancer remains the second most common cause of cancer-related death in Europe and North America. More than 50% of patients develop liver metastases within their lifetime and liver resection remains their only chance of cure. Recent trends in liver surgery have favoured parenchyma-preserving liver surgery over traditional major hepatectomies. 1 The aim of this study was to investigate the trend in approach to liver surgery over a 15-year period at a high-volume hepatobiliary unit. Methods A prospectively maintained database containing data for the resection of colorectal liver metastases was analysed from 1995 to 2010. Demographic data were extracted together with data on types of liver resection, morbidity and mortality rates, and major vs minor hepatectomies. Minor hepatectomy was defined as any resection up to three segments and major hepatectomy was more than three segments resected. Data displayed compare the three 5-year periods from: 1995 to 1999, 2000 to 2004 and 2005 to 2009. Results A total of 1414 hepatectomies were undertaken from 1995 up to 2010. 172 resections were performed in 1995–1999, 570 in 2000–2004 and 672 in 2005–2009. Median age and range were as follows: 61 years (36–80 years) in 1995–1999, 65 years (32–87 years) in 2000–2004, and 65 years (23–91 years) in 2005–2009. Major vs minor hepatectomy ratio were as follows: 55:45 in 1995–1999, 45:55 in 2000–2004, and 33:67 in 2005–2009. Complication rates were as follows: 29.1% in 1995–1999, 23.5% in 2000–2004, and 15.9% in 2005–2009. Mortality rates were significantly reduced from 9.3% in 1995–1999, and 3.3% in 2000–2004, to 1.9% in 2005–2009 (P Conclusion The trend in liver resection has been towards more segmentectomies and metastasectomies rather than the more traditional major anatomical resections. This has been associated with a decreased complication rate and a significantly reduced mortality rate. This may reflect not only improvements in technique and critical care management but also in the paradigm shift towards parenchyma-preserving liver surgery. Local recurrence and survival rates will dictate whether this is the optimal treatment. Competing interests None declared. Reference 1. von Heesen M , Schuld J, Sperling J, et al. Parenchyma-preserving hepatic resection for colorectal liver metastases. Langenbecks Arch Surg 2011.