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Aim We undertook this study to evaluate the influence of resection margin distance from metastases on survival and post-operative disease recurrence after hepatectomy for colorectal liver metastasis. Methods Between January 1993 and December 2001, 293 consecutive patients underwent primary liver resection for colorectal metastasis. Clinical, pathological and outcome data were analysed using a prospectively collected database. Cases were stratified into those with involved and non-involved resection margins. Different non-involved margin widths were analysed against survival, recurrence rate and pattern (hepatic, extra hepatic) of recurrence. Results The 1, 3, 5 and 10 years actuarial survival rates were 82, 58, 44 and 36%, respectively. The median survival was 46 months. The histological liver resection margin involvement was a significant predictor of survival and disease free survival after surgery. One, two, five and 10 millimetres disease free resection margin widths were found not to be significant in influencing patients' survival or recurrence rate. Conclusion A positive hepatic resection margin was associated with a higher incidence of post-operative recurrence and lower survival rate. The width of the resection margin did not influence the post-operative recurrence rate or pattern of recurrence. The ‘1 cm rule’ should be abandoned.

Introduction Sinusoidal obstructive syndrome (SOS) is well associated with the use oxaliplatin-based chemotherapy, and represents a spectrum of hepatotoxicity, with nodular regenerative hyperplasia (NRH) representing the most significant degree of injury. The aim of this study was to determine the prevalence of NRH in patients undergoing resection of colorectal liver metastases (CRLM) and to determine its impact on outcome. Methods From January 2000 to December 2010, some 978 first primary liver resections were performed for CRLM. A prospectively maintained database was analysed to identify all patients with evidence of NRH in the non-tumour portion of their histopathology specimens. Clinical data of these patients was reviewed and outcomes assessed. Results Five patients exhibited NRH (four males, one female) with a median age of 69 years (range: 35–74). Three patients presented with synchronous hepatic metastases, and two with metachronous lesions. All received at least 6 cycles of oxaliplatin as either adjuvant or neo-adjuvant chemotherapy. Only one patient developed a post-operative complication namely transient hepatic failure that required a 4-day stay in the intensive care unit. The median hospital stay was 6 days (range: 6–14 days). There were no 90-day mortalities. One patient is alive and disease free at 55 months, the remaining 4 died of recurrent disease between 37 and 70 months following diagnosis of their primary tumours. Conclusions NRH is not an uncommon finding amongst patients with SOS with all patients having received oxaliplatin-based chemotherapy. Data on outcome would suggest no increased morbidity and mortality associated with the presence of NRH.

A 28 year old woman was admitted at 39 weeks of gestation to the labour suite having developed lower abdominal pain and contractions. On admission her pulse and blood pressure were normal and there was no proteinuria. The pregnancy had been uncomplicated with no evidence at antenatal screening of hypertension or proteinuria. She had a normal vaginal delivery under epidural anaesthesia and a healthy male infant was delivered. Total blood loss was 100 ml and a small vaginal tear was repaired. One hour after delivery she developed central pleuritic chest pain, and became tachycardic and hypoxic (oxygen saturation falling to 64%). Cardiovascular parameters, liver function tests, full blood count, clotting screen, chest Xray and ECG were all normal. There was a high suspicion of pulmonary embolism and intravenous heparin was therefore commenced. She remained stable for the next 14 hours, then developed sudden severe pain in the neck, right shoulder, and the epigastrium. She became tachycardic (130 per minute) but maintained her blood pressure (130/80). The full blood count, clotting screen and liver function tests remained normal apart from alanine amino-tranferase, which was increased at 240 u/L. Three hours later her blood pressure suddenly dropped to 60/40 with an associated alteration in her level of consciousness. The possibility of meningococcal infection was considered. She was transferred to the intensive care unit for closer monitoring and responded transiently to uid resuscitation. Two hours later she again became hypotensive and on examination was noted to have a tender distended abdomen, which had not been clinically evident previously. The most likely diagnosis was thought to be intra-peritoneal haemorrhage from a ruptured uterus and therefore a laparotomy was undertaken. At operation, ®ve litres of blood were drained from the peritoneum and multiple bleeding points on the surface of the right lobe of the liver were seen with the liver capsule stripped off from its surface at this point. Diathermy and haemostatic sponges were used in an attempt to stop the bleeding. A drain was inserted, the abdomen closed, and she was transferred back to the intensive care unit. She remained haemodynamically unstable during the night, requiring a total of 24 units of blood (as well as platelets and cryoprecipitate) to maintain her blood pressure. Despite this aggressive treatment regimen, she remained unstable and developed a low platelet count, deranged clotting and ensuing disseminated intravascular coagulation (DIC). She was transferred to the regional liver unit because of continued blood loss. On arrival she had an abdominal CT scan which showed an enlarged congested liver with a haematoma covering its surface (Fig. 1). The contrast enhanced CT of the abdomen revealed patchy perfusion in the right lobe (suggesting of areas of infarction) and a poorly de®ned right portal venous system raising the possibility of occlusion of right portal vein. The left lobe of the liver was well perfused with a patent left portal vein (Fig. 2). She subsequently had a second laparotomy at which she was found to have six litres of haematoma surrounding a congested liver. The portal vein and hepatic veins were patent and there was no evidence of focal infarction. There was general oozing from the surface of the liver but no focal bleeding points were found. A biopsy of the liver was taken and the bleeding stopped using Argon diathermy. Post-operatively she remained unstable requiring further transfusion of fresh frozen plasma, platelets and blood. Her condition slowly deteriorated with ensuing acidosis and eventually, 16 hours after her second operation, she died following an asystolic cardiac arrest from which she could not be resuscitated. Although the CT scan had raised the possibility of occlusion of right portal vein, the post-mortem examination of the liver did not show any evidence of this. The histological report of the liver biopsies revealed congestion, ischaemic degeneration and areas of microscopic infarction not speci®c of

The aim of this study was to identify the number of accidents and types of injury related to the Supertram system in Sheffield. Data was collected prospectively over an 18 month period, commencing in April 1994, on all patients attending the Accident and Emergency department at the Royal Hallamshire Hospital whose injuries were related to the tram system. Ninety patients were included in the study, 54 males and 36 females with a median age of 39 years (range 16-82), representing approximately 0.13% of the patients attending the department during the study period. Forty one patients were cyclists, twenty three pedestrians, twelve were motorists or motorcyclists and fourteen sustained injuries due to ongoing construction work. Thirty one patients sustained fractures, most commonly involving the upper limb/shoulder girdle (63%), with cyclists suffering 83% of these serious upper limb injuries. Following assessment 38 patients were discharged, 29 patients were referred to fracture clinic, 12 were sent for physiotherapy and 11 admitted to hospital. Eight patients required a total of 13 operations during the study period. We have demonstrated a significant number of injuries in this study related to the tram system in Sheffield. Cyclists appear to be the group at highest risk, followed by pedestrians and motor vehicle users.