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Background The International Study Group for Liver Surgery (ISGLS) definition of post hepatectomy liver failure (PHLF) was developed to be consistent, widely applicable, and to include severity stratification. This international multicentre collaborative study aimed to prospectively validate the ISGLS definition of PHLF. Methods 11 HPB centres from 7 countries developed a standardised reporting form. Prospectively acquired anonymised data on liver resections performed between 01 July 2010 and 30 June 2011 was collected. A multivariate analysis was undertaken of clinically important variables. Results Of the 949 patients included, 86 (9%) met PHLF requirements. On multivariate analyses, age ≥70 years, pre-operative chemotherapy, steatosis, resection of >3 segments, vascular reconstruction and intraoperative blood loss >300 ml significantly increased the risk of PHLF. Receiver operator curve (ROC) analysis of INR and serum bilirubin relationship with PHLF demonstrated post-operative day 3 and 5 INR performed equally in predicting PHLF, and day 5 bilirubin was the strongest predictor of PHLF. Combining ISGLS grades B and C groups resulted in a high sensitivity for predicting mortality compared to the 50-50 rule and Peak bilirubin >7 mg/dl. Conclusions The ISGLS definition performed well in this prospective validation study, and may be the optimal definition for PHLF in future research to allow for comparability of data.

Background There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. Methods The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of “patency” and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. Results The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. Conclusions A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.

This multicentre, randomized clinical trial assessed the safety and effectiveness of the EVARREST™ Fibrin Sealant Patch (FP) in treating parenchymal bleeding following anatomic and non-anatomic liver resections.One hundred and two patients were stratified according to the type of hepatic resection (anatomic/non-anatomic), and randomized (1:1) after identification of an appropriate bleeding site, to FP vs Standard of Care (SoC, manual compression ± topical haemostat). The primary endpoint was haemostasis at 4 min from bleeding site identification with no re-bleeding requiring re-treatment.The FP was superior in achieving haemostasis at 4 min (96%, 48/50) to SoC (46%, 24/52; p 0.001). Stratification for resection type showed treatment differences for primary endpoint for anatomic (24/25 FP vs 13/23 SoC; p = 0.001) and non-anatomic liver resections (24/25FP vs 11/29 SoC; p 0.001). Adverse events related to the study procedure were reported in 40/50 patients (80%) in the FP group and 43/52 patients (83%) in the SoC group. One (2%) adverse event (infected intra-abdominal fluid collection) was possibly related to study treatment.This clinical trial confirms that the FP is safe and highly effective in controlling parenchymal bleeding following hepatectomy regardless of the type of resection. ClinicalTrials.gov NCT01993888.

BackgroundThe effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.ObjectiveThe aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.MethodsA retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan–Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox's proportional hazards methods.ResultsA total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4–10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2–11.9 years) (log-rank test, P=0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72–2.176; P=0.019] along with age (HR: 1.062; P

IntroductionHaemostasis after liver resection may be difficult to achieve as a result of the presence of challenging bleeding, the anatomic landscape of the liver and the quality of tissue making up the hepatic parenchyma. The fibrin pad (FP) is a topical absorbable haemostat designed to be effective in a variety of tissues and across multiple bleeding intensities. This is the first clinical trial to evaluate the hemostat's safety and effectiveness in controlling bleeding during elective hepatic resection.MethodsThis prospective, randomized, controlled superiority trial enrolled 104 subjects undergoing elective hepatectomy in 5 countries. After parenchymal transection, subjects with an appropriately defined target bleeding site (TBS) were stratified according to the type of hepatic parenchyma and immediately randomized 1:1: FP versus Standard of Care (SoC). SoC comprised manual compression with the use of an approved topical absorbable haemostat. The primary endpoint was haemostasis at 4 min from identification of the TBS, with no re‐bleeding requiring re‐treatment prior to abdominal closure. Results were stratified for both normal and abnormal (steatosis or cirrhosis) hepatic parenchyma. All subjects were followed for 60 days post‐operatively.ResultsThe intent‐to‐treat (ITT) analysis showed an overall treatment difference of 53.0% (P < 0.001), 82.5% (33/40 FP) versus 29.5% (13/44 SoC) in achieving haemostasis at 4 min with no re‐bleeding requiring treatment up to wound closure. The per protocol analysis showed an overall treatment difference of 65.7% (P < 0.001), with 33/35 successes (94.3%) in the FP group and 12/42 in the SoC group (28.6%). The stratification results showed treatment differences between the normal parenchyma group, 63.6% (95.8% FP versus 32.3% SoC P < 0.001) and a larger difference of 72.7% in the abnormal parenchyma group (90.9% FP versus 18.2% SoC P = 0.0003). Post‐operative intra‐abdominal fluid collections were less frequent in the FP group (3.4% FP versus 13.3% SoC P = 0.059). There was no difference in the safety profile between the FP or SoC groups.ConclusionsThe FP is safe and effective when used as an adjunct to achieve haemostasis during hepatic surgery. The success rate of achieving haemostasis with a FP remained high compared with the SOC group, especially in steatotic or cirrhotic liver tissue where the control success rates diminish. In addition, FP treatment of hepatic parenchymal surfaces may reduce the risk of post‐operative biliary and fluid collections.

ObjectivesEpidural analgesia is recommended for the provision of analgesia following major abdominal surgery. Continuous local anaesthetic wound infiltration may be an effective alternative. A prospective randomized trial was undertaken to compare these two methods following open liver resection. The primary outcome was length of time required to fulfil criteria for discharge from hospital.MethodsPatients undergoing open liver resection were randomized to receive either epidural (EP group) or local anaesthetic wound infiltration plus patient-controlled opiate analgesia (WI group) for the first 2days postoperatively. All other care followed a standardized enhanced recovery protocol. Time to fulfil discharge criteria, pain scores, physical activity measurements and complications were recorded.ResultsBetween August 2009 and July 2010, 65 patients were randomized to EP (n= 32) or WI (n= 33). The mean time required to fulfil discharge criteria was 4.5days (range: 2.5–63.5days) in the WI group and 6.0days (range: 3.0–42.5days) in the EP group (P= 0.044). During the first 48h following surgery, pain scores were significantly lower in the EP group both at rest and on movement. Resting pain scores within both groups were rated as mild (range: 0–3). There was no significant difference between the groups in time to first mobilization or overall complication rate (48.5% in the WI group vs. 58.1% in the EP group; P= 0.443).ConclusionsLocal anaesthetic wound infiltration combined with patient-controlled opiate analgesia reduces the length of time required to fulfil criteria for discharge from hospital compared with epidural analgesia following open liver resection. Epidural analgesia provides superior analgesia, but does not confer benefits in terms of faster mobilization or recovery.

Objectives:Epidural analgesia is often considered the reference standard for pain relief following major abdominal surgery; however, the provision of analgesia in the context of liver surgery raises unique challenges. This study investigated the effectiveness of analgesia and the postoperative course of patients who did or did not receive epidural analgesia following liver resection.Methods:Data were collected retrospectively on 177 patients who underwent open liver resection between June 2007 and June 2009. Patients were divided into two groups consisting, respectively, of those who received epidural analgesia (Epidural group, n = 148) and those who did not (No-Epidural group, n = 29).Results:In the Epidural group, 27 patients (18%) required i.v. opiate analgesia on the day of surgery (DoS) or the first postoperative day (POD1). The Epidural group received significantly more i.v. colloid solution on the DoS (median: 1500 ml vs. 750 ml, range: 0-12 000 ml vs. 0-3500 ml; P = 0.004) and POD1 (median: 0 ml vs. 0 ml, range: 0-5000 ml vs. 0-1000 ml; P = 0.018), and total fluid on the DoS and POD1 combined (median: 6522 ml vs. 5453 ml, range: 2150-21 300 ml vs. 2875-15 886 ml; P = 0.032).Conclusions:Epidural analgesia provided inadequate postoperative pain relief in approximately 20% of liver resection patients and was associated with the administration of significantly greater volumes of i.v. colloid solution.

Background: Despite the increasing use of laparoscopic techniques, the optimal surgical approach for cystic liver disease has not been well defined. This study aims to determine the optimum operative approach for these patients.Methods: Data were identified from the Lothian Surgical Audit, case note review and general practitioner contact. Patients were contacted and asked to complete the SF-36 questionnaire on quality of life.Results: A total of 102 patients (67 with simple cysts, 31 with polycystic liver disease [PCLD], four with cystic tumours) underwent 62 laparoscopic deroofings, 15 open deroofings, 36 resections and one liver transplant between June 1985 and April 2006. The median follow-up was 77 months (range 3-250 months). Morbidity and recurrent symptom rates after laparoscopic surgery were greater in PCLD patients compared with simple cyst patients, at 31% (four patients) vs. 15% (seven patients) and 85% (11 patients) vs. 29% (24 patients), respectively. Four patients with simple cysts and eight with PCLD required further surgery. All patients with simple cysts had comparable quality of life after surgery. Patients with recurrent symptoms after surgery for PCLD had a significantly better quality of life following laparoscopic deroofing than after resection.Conclusions: Most simple cysts can be managed laparoscopically, but there is a definite role for open resection in some patients. Open deroofing is the preferred approach for a dominant cyst pattern in PCLD, whereas resection is necessary for diffuse cystic disease.

The precise role of laparoscopic assessment of biliary tract malignancy is yet to be defined. The evidence for its use has been reviewed to establish the role of laparoscopy for preoperative staging of cholangiocarcinoma. Published papers were reviewed for the evidence relevant to intrahepatic, proximal intrahepatic and distal biliary carcinoma. There is no randomized trial evaluating staging laparoscopy or laparoscopic ultrasound in the assessment of cholangiocarcinoma and the quality of the available data is extremely variable. There is a need for further studies to determine the specific role of laparoscopic staging of cholangiocarcinoma. The current standard of management should be to perform laparoscopic staging prior to proceeding to resection for patients with cholangiocarcinoma as it may prevent unnecessary laparotomy in up to 30% of patients. However, a selective approach identifying high-risk patients who will not benefit from surgical palliation may be more cost effective and future studies should be performed to identify such patients.

Background and aims: Pancreaticoduodenectomy (PD) is a major operative intervention performed most commonly for malignancy in the head of pancreas. The aim of this study was to evaluate the utilization of blood transfusion for PD and to determine whether this had prognostic significance in a subset of patients with pancreatic ductal adenocarcinoma (PDAC). Material and methods: Data on blood transfusion requirement were retrospectively collected for patients undergoing PD from 1998 to 2005. Standard prognostic factors and survival data were also collected in patients with PDAC. Results: One-hundred-and-seventy patients underwent PD. Seventy-six patients (45%) received transfusion. The median (interquartile range) number of units of red cell concentrate (RCC) transfused perioperatively (intraoperatively and within 24h of surgery) was 1.5 (0.5–2.5). The median preoperative haemoglobin (Hb) was 126 g/dl. The median number of units of RCC transfused perioperatively in patients with Hb

Introduction. A vast majority of patients with chronic pancreatitis require regular opiate/opioid analgesia and recurrent hospital admission for pain. However, the role and timing of operative strategies for pain in chronic pancreatitis is controversial. This study hypothesized that pancreatic decompression surgery reduces analgesia requirement and hospital readmission for pain in selected patients. Patients and methods. This was a retrospective review of patients undergoing longitudinal pancreatico-jejunostomy (LPJ), with or without coring of the pancreatic head (Frey's procedure), between 1995 and 2007 in a single UK centre. Surgery was performed for chronic pain with clinical/radiological evidence of chronic pancreatitis amenable to decompression/head coring. Results. Fifty patients were identified. Thirty-six were male with a median age of 46 years and median follow-up of 30 months. Twenty-eight underwent LPJ and 22underwent Frey's procedure. No significant difference in reduction of analgesia requirement (71% vs 64%, p =0.761) or hospital readmission for pain (21% vs 23%, p =1.000) was observed when comparing LPJ and Frey's procedure. Patients were significantly more likely to be pain-free following surgery if they required non-opiate rather than opiate analgesia preoperatively (75% vs 19%, p =0.0002). Fewer patients required subsequent hospital readmission for pain if taking non-opiate rather than opiate analgesia preoperatively (12.5% vs 31%, p =0.175). Conclusions. In selected patients, LPJ and Frey's procedure have equivalent benefit in short-term pain reduction. Patients should be selected for surgery before the commencement of opiate analgesia.

The value of lung ultrasonography in the diagnosis of respiratory dysfunction and severity stratification in patients with acute pancreatitis (AP) was investigated.Over a 3-month period, 41 patients (median age: 59.1 years; 21 males) presenting with a diagnosis of potential AP were prospectively recruited. Each participant underwent lung ultrasonography, and the number of comet tails present on scans was linked with contemporaneous clinical data. Group comparisons, areas under the curve (AUC) and respective measures of diagnostic accuracy were investigated.A greater number of comet tails were evident in patients with respiratory dysfunction (P = 0.013), those with severe disease (P = 0.001) and when contemporaneous and maximum in-patient C-reactive protein (CRP) exceeded 150 mg/l (P = 0.018 and P = 0.049, respectively). Receiver-operator characteristic plot area under the curve (AUC) was greater when examining upper lung quadrants, using respiratory dysfunction and AP severity as variables of interest (AUC = 0.803, 95% CI: 0.583-1.000, and AUC = 0.996, 95% CI: 0.983-1.000, respectively). Examining all lung quadrants resulted in greater AUCs for contemporaneous and maximum CRP (AUC = 0.764, 95% CI: 0.555-0.972, and AUC = 0.704, 95% CI: 0.510-0.898).Ultrasonography of non-dependent lung parenchyma can reliably detect evolving respiratory dysfunction in AP. This simple bedside technique shows promise as an adjunct to severity stratification.

Background The Scientific Committee of the IHPBA, meeting in December 1998, created a Terminology Committee to deal with the confusion in nomenclature of hepatic anatomy and liver resections. A terminology was sought which was anatomically correct, in which anatomical and surgical terms agreed, and which was consistent, self-explanatory, linguistically correct, translatable, precise and concise. Discussion After 18 months the International Committee presented a terminology that was accepted by the IHPBA at the recent World Congress in Brisbane. The purpose of this paper is to present that terminology.

Background Internal biliary drainage is known to reverse many of the pathophysiological disturbances seen in jaundiced patients. However, previous studies examining the effectiveness of preoperative biliary drainage in reducing morbidity and mortality rates in patients undergoing surgical intervention have been disappointing. The aim of this study was to evaluate the effect of preoperative biliary stenting on the incidence of bacterobilia and postoperative complications following surgical treatment of hilar cholangiocarcinoma. Methods Between 1988 and 1998, 127 patients with hilar cholangiocarcinoma were managed in a tertiary referral unit. Forty seven of these patients (37%) underwent curative resection or palliative biliary bypass procedures. Postoperative morbidity and mortality rates were compared in patients who had preoperative biliary drainage (PBD) (n = 20) and those who had no preoperative biliary drainage (NPBD) (n = 27). Results The median bilirubin concentration fell significantly in the PBD group after stent insertion and was significantly lower than in the NPBD group at the time of surgical intervention (110 mmol/L in PBD group versus 335 mmol/L in NPBD group; p Discussion Preoperative biliary drainage for hilar cholangiocarcinoma significantly increases the incidence of contaminated bile. A satisfactory period of preoperative biliary drainage does not reduce the incidence of postoperative complications in patients undergoing surgical intervention and is associated with increased hospital stay.

Background Peritoneal cytology may be useful in the preoperative assessment of patients with pancreatic cancer. Method A prospective study was undertaken to evaluate the contribution of peritoneal cytology performed during staging laparoscopy in 46 patients with pancreatic or periampullary cancer. Results Laparoscopic peritoneal cytology was positive for the presence of malignant cells in seven patients (15%). All seven patients with positive peritoneal cytology had laparoscopic evidence of tumour unresectability. Negative peritoneal cytology results were obtained in 39 patients, 13 of whom were deemed to have resectable tumours. The median cumulative survival at 6 months was 8% for patients with positive cytology, compared with 71% for those with negative cytology. Discussion Positive peritoneal washings are an indicator of advanced disease and may be a useful adjunct to staging laparoscopy in the detection of patients with unresectable tumours.