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Introduction: Large epidemiological studies have demonstrated the link between metabolic syndrome and cancer development, including colorectal cancer. However, the influence of metabolic syndrome on disease progression is less well studied, particularly in the post-surgical setting. This study investigates the effect of metabolic syndrome on colorectal cancer recurrence (all-site and liver-specific) after curative surgery for Stage I-III disease. Materials and methods: Consecutive patients who underwent curative resection for Stage I-III colorectal cancer in a single UK centre were prospectively recruited. Disease-free and overall survival with metabolic syndrome as a factor, were determined using the Kaplan-Meier technique. Hazard ratios for all-site and liver-specific recurrence were determined using univariable and multivariable Cox-regression models. Results: 1006 patients were recruited and followed up for a median of 50 months (IQR 30–67). 177 patients (17.6%) met the criteria for metabolic syndrome. 245 patients (25.4%) developed recurrence, 161 (16.0%) of these had liver recurrence. The presence of metabolic syndrome was associated with a reduction in disease-free survival from 69 to 58 months (p < 0.001) and overall survival from 74 to 61 months (p < 0.001). Metabolic syndrome was an independent predictor of all-site (HR 1.76; p < 0.001) and liver-specific (HR 1.74; p = 0.01) recurrence. Conclusion: Metabolic syndrome is a predictor of all-site and liver-specific recurrence after primary resection of stage I-III colorectal cancer.

Background: Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as ‘textbook outcome’ (TBO). Methods: In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012–January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009–April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test. Results: The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005). Conclusion: Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS.

Serum aminotransferases have been used as surrogate markers for liver ischemia-reperfusion injury that follows liver surgery. Some studies have suggested that rises in serum alanine aminotransferase (ALT) correlate with patient outcome after liver resection. We assessed whether postoperative day 1 (POD 1) ALT could be used to predict patient morbidity and mortality following liver resection. We reviewed our prospectively held database and included consecutive adult patients undergoing elective liver resection in our institution between January 2013 and December 2014. Primary outcome assessed was correlation of POD 1 ALT with patient's morbidity and mortality. We also assessed whether concurrent radiofrequency ablation, neoadjuvant chemotherapy and use of the Pringle maneuver significantly affected the level of POD 1 ALT. A total of 110 liver resections were included in the study. The overall in-hospital patient morbidity and mortality were 31.8% and 0.9%, respectively. The median level of POD 1 ALT was 275 IU/L. No correlation was found between POD 1 serum ALT levels and patient morbidity after elective liver resection, whilst correlation with mortality was not possible because of the low number of mortalities. Patients undergoing concurrent radiofrequency ablation were noted to have an increased level of POD 1 serum ALT but not those given neoadjuvant chemotherapy and those in whom the Pringle maneuver was used. Our study demonstrates POD 1 serum ALT does not correlate with patient morbidity after elective liver resection.

Introduction Despite advances in surgical and anaesthetic techniques made over the last 2 decades, right hepatic trisectionectomy (RHT) is still a challenging procedure associated with higher rates of morbidity and mortality. Some patients may even require further extension of the resection to include part of segments II/III to achieve clearance (extended right hepatic trisectionectomy, ERHT). Aim of the study was to assess and compare the early and long-term outcomes of RHT and ERHT in our Unit. Methods From January 1993 to December 2010, 252 RHT and 80 ERHT were performed (n=332). Resection for colorectal liver metastases (CRLM), HCC, cholangiocarcinoma and other were 127, 43, 25 and 57 for RHT and 60, 3, 2, 15 for ERHT respectively. Mean age was 58.3 vs 57.9 and 57.1% vs 55% were males (RHT vs ERHT, p=NS). There were 61 caudatectomy in the RHT group and 15 in the ERHT (p=0.36, NS); vascular resection (IVC or PV) was performed in 61 and 10 cases (p=0.18, NS), biliary reconstruction was performed in 75 and 7 cases (p=0.01) and total vascular exclusion was necessary in 26 and 6 cases respectively (p=NS). The amount of functional hepatic remnant was based on intra-operative judgement. Results There were 23 in-hospital deaths (6.9%, RHT: 19, ERHT: 4; p=NS). Overall morbidity was 44% (RHT) and 47.5% (ERHT). Bile leak (17 vs 3), haemorrhage (14 vs 4), sepsis (33 vs 9), cardio-vascular events (12 vs 1) and renal failure (12 vs 3) did not differ among the two groups (RHT vs ERHT; p=NS). There were 42 (12.6%) post-hepatectomy liver failure (according to “50:50 criteria”): 23 in the RHT group and 19 in the ERHT group respectively (p=0.001). Mean hospital stay was 15.8 vs 17.1 days (RHT vs ERHT, p=NS). In the CRLM cohort, 1, 5 and 10 year survival was 78%, 47% and 39% vs 79%, 47% and 37% (RHT vs ERHT, p=0.93, NS). Median survival was 49 and 43.9 months respectively (p=NS) and median follow-up was 59.7 and 56.5 months (RHT vs ERHT). Conclusion RHT and ERHT are a major undertaking with significant morbidity and mortality but represent the only chance of cure in selected patients. Liver failure is higher in the ERHT group but does not translate in increased mortality. Long-term survival in CRLM is achievable and does not differ among the two groups. Extensive liver resections even beyond conventional boundaries should not be considered an absolute contraindication to surgery. Competing interests None declared.