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Background Pancreaticoduodenectomy is the only curative treatment option for patients with resectable ampullary adenocarcinoma (AA). Excellent disease free survival (DFS) can be achieved in patients with clear resection margins but it is poorly understood which patients are at increased risk of recurrence and hence would benefit from adjuvant chemotherapy. There is evolving evidence that the anatomical location of incomplete resection margins influences DFS in pancreatic adenocarcinoma. It is unknown if this also pertains to AA and therefore this study aimed to assess individual resection margin status and other predictors of DFS in AA. Material & methods Consecutive patients undergoing pancreaticoduodenectomy for AA at our institution from 1996 to 2017 were analysed. Pancreas neck, posterior and superior mesenteric vein margins were assessed individually. Cox proportional hazards modelling was used to identify predictors of 5-year DFS. Factors with p Results Analysis of 104 patients revealed median OS and DFS of 56 and 34 months, respectively. Predictors associated with worse DFS on multivariate analysis were T3-stage (HR 3.6, p = 0.048), N1 (HR 2.9, p = 0.01) and N2 -stage (HR 3.6, p = 0.006), R1 status at the posterior margin (HR 3.0, p = 0.009) and a visible mass on CT (HR 2.0, p = 0.039). Conclusion Routine histopathological assessment of individual resection margins may aid in predicting recurrence of AA. Future studies to assess if routine mesopancreas excision during pancreaticoduodenectomy can reduce the incidence of R1 status at the posterior margin are warranted.

Highlights • Solitary pancreatic tail lesion should undergo nuclear scintigraphy to assess whether the lesion is compatible with a splenunculus., Introduction Mass lesions in the pancreatic tail are increasingly identified upon radiological imaging. However the diagnosis of these lesions can be challenging and impact significantly upon patient management. Presentation of case We report a case of an intrapancreatic accessory spleen initially diagnosed as a neuroendocrine tumour of the pancreas tail following nuclear scintigraphy. Discussion The investigation of solitary pancreatic tail lesions and the potential management paradigms are discussed. Conclusion Solitary lesions within the pancreatic tail should have splenunculus included in the differential diagnosis.

Surgical options and approaches to pancreatic cancer are changing in the current era. Neoadjuvant treatment strategies for pancreatic cancer combined with the increased use of minimal access surgical techniques mean that the modern pancreatic surgeon requires mastering a number of surgical approaches with to optimally manage patients. Whilst traditional open surgery remains the most frequent approach for surgery, the specific steps during surgery may need to be modified in light of the aforementioned neoadjuvant treatments. Robotic and laparoscopic approaches to pancreatic resection are feasible, but these surgical methods remain in their infancy. In this review article, we summarise the current surgical approaches to pancreatic cancer and how these are adapted to the minimal access setting with discussion of the patient outcome data.

Oesophageal cancer is the ninth most common cancer in the UK. With 8500 cases diagnosed annually, the UK has the highest rates of oesophageal cancer in Western Europe. Adenocarcinoma now accounts for 60–75% of all oesophageal cancers in the UK and is three to four times more common in men. Despite advances in diagnosis and treatment, five-year survival rates for all patients diagnosed with oesophageal cancer ranges from 15–20%. In this article the authors discuss current diagnosis and management.

The importance of preoperative chemotherapy in a multimodality management of patients with colorectal liver metastases (CRLM) has been demonstrated. We analyse the carcinoembryonic antigen (CEA) changes following neoadjuvant chemotherapy in patients with CRLM who underwent liver resection. The final cohort included 107 eligible patients. Increased CEA levels following neoadjuvant chemotherapy were defined as the increase of baseline CEA level at diagnosis of CRLM compared with the CEA level after completion of neoadjuvant chemotherapy. Disease-free survival (DFS), post-recurrence survival (PRS) and overall survival (OS) were calculated using both Kaplan-Meier and multivariate Cox-regression methods. CEA increase was associated with decreased PRS and OS (HR 2.69; 95 % CI, 1.28–5.63; p = 0.009, and HR 2.50; 95 % CI, 1.12–5.56; p = 0.025, respectively) in multivariate analysis, but there was no association between CEA changes and DFS. CEA increase was only associated with disease progression during preoperative chemotherapy (p = 0.014). Interestingly, this association was not absolute, as only 5 of the 11 patients with disease progression demonstrated CEA increase. Regarding the remaining 12 patients with CEA increase, according to RECIST criteria, eight patients demonstrated partial response and four patients stable disease. In this study, we demonstrated the CEA increase following neoadjuvant chemotherapy as an adverse prognostic factor for PRS, and OS but not for DFS in patients undergoing liver resection for liver-only colorectal metastases.

SUMMARY Aim: Patients with colorectal liver metastases (CRLM) benefit from liver resection. Bevacizumab is commonly used in these patients resulting in a greater number of patients receiving an operation for a potentially curative liver resection, with initially unresectable liver metastases. Our purpose was to evaluate the effect of preoperative bevacizumab administration on perioperative complications in patients undergoing hepatic resection for CRLM. Methods: A retrospective analysis of patients undergoing hepatic resection for CRLM who received only neoadjuvant chemotherapy (chemotherapy group, n = 133), or neoadjuvant chemotherapy and bevacizumab (chemotherapy and bevacizumab group, n = 103). We compared surgical characteristics, perioperative complications and postoperative liver function. Results: The type of liver resection (minor vs major liver resection) was comparable in the two groups (major liver resection 52.6 vs 62.1%, p = 0.144). The addition of bevacizumab to preoperative chemotherapy does not affect the frequency (chemotherapy group vs chemotherapy and bevacizumab group, 35.3 vs 38.8%, p = 0.581), severity (major complications, 20.3 vs 19.4%, p = 0.487) and type of perioperative complications. Preoperative administration of bevacizumab was associated with a higher peak of postoperative alanine aminotransferase levels but did not affect functional recovery of the liver. Conclusion: Neoadjuvant administration of bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection and did not affect the liver's functional recovery. Patients receiving more than eight cycles of bevacizumab are at an increased risk to develop perioperative complications.

PEComa is a family of rare mesenchymal tumours which can occur in any part of the human body. Primary PEComas of the pancreas are extremely rare tumours with uncertain malignant potential. A 17-year-old female was admitted to the hospital due to melena. She required several transfusions. CT scan demonstrated a mass at the head of the pancreas measuring 4.2 cm in maximum diameter. An endoscopic ultrasound showed an ulcerating malignant looking mass infiltrating 50% of the wall of the second part of the duodenum in the region of the ampulla. Multiple biopsies taken showed extensive ulceration with granulation tissue formation and underlying large macrophages without being able to establish a definite diagnosis. We proceeded with pylorus-preserving pancreaticoduodenectomy. The postoperative course of the patient was unremarkable, and she was discharged on the 8th postoperative day. Histology examination of the specimen showed a PEComa of pancreas. Eighteen months after resection the patient is disease free. To the best of our knowledge this is the first time we describe a case of a pancreatic PEComa presenting with massive gastrointestinal bleeding.

ObjectiveWe investigate the neutrophil to lymphocyte ratio (NLR) as a potential prognostic factor for patients undergoing curative liver resection for colorectal liver metastasis (CRLM). MethodsWe identified patients who underwent liver resection, via our prospectively accumulated surgical database at the Royal Marsden Hospital and The London Clinic, by two liver surgeons (SM and AZK) between January 2005 and December 2012 and patients included had liver resection for CRLM and received preoperative chemotherapy with an NLR>2.5 considered elevated. NLR's role in disease-free, post-recurrence and overall survival was determined by univariate and multivariate Cox regression models. ResultsOne hundred and sixty nine patients were enrolled. Seventy-one patients (42%) demonstrated NLR>2.5. Elevated NLR was associated with decreased OS in univariate and multivariate analysis (HR 2.12; 95% CI, 1.18-3.82; P=0.012) but not with DFS. Analyzed as continuous variable, higher NLR was associated with decreased OS(HR 1.17; 95% CI, 1.03-132; P=0.011) and associated with increased risk of extrahepatic/multifocal recurrence (P=0.007), linked in this way with a decreased post-recurrence survival (HR 1.24, 95% CI, 1.02-1.52; P=0.032). ConclusionsElevated NLR in patients who undergo hepatectomy following neoadjuvant chemotherapy for CRLM increases risk of extrahepatic/multifocal recurrence and is an independent predictor of overall survival. J. Surg. Oncol. 2015 111:445-450. (c) 2014 Wiley Periodicals, Inc.

The impact of postoperative morbidity, and in particular infective complications on long-term outcomes, following hepatic resection for colorectal liver metastasis (CRLM) is not widely published.To evaluate the effect of postoperative complications on disease recurrence and overall survival in patients undergoing hepatic resection for CRLM.All patients undergoing hepatic resection for CRLM from January 1993 and March 2007 were identified, and postoperative complications analyzed. Patients who died of postoperative complications within 30 days of surgery were excluded form the study. Postoperative complications were graded using a validated system of classification. Complications were further classified into infective and noninfective complication groups and the primary end points of the study were disease free survival (DFS) and overall survival (OS) at 5 years.A total of 705 patients underwent hepatic resection in the study period. Median follow-up was 38 months. Operative morbidity and mortality were 28% and 3.6%, respectively. The total number of patients was 197 (28%) with complications, and 508 (72%) without complications. The 5 year DFS and OS for those with and without complications were: 13% versus 26% (P0.001) and 24% versus 37% (P0.001), respectively. Multivariate analysis showed inflammatory response to tumor score, blood transfusion, tumor number8, and postoperative sepsis to be independent factors associated with DFS, and inflammatory response to tumor, tumor number8, and postoperative sepsis to be independent predictors for OS. Intra-abdominal and respiratory infection but not wound infections were associated with poorer long-term outcomes.Postoperative complications influence long-term outcomes in hepatic resection for CRLM. Specifically, postoperative sepsis is an independent predictor of disease free and overall survival. Thorough preoperative optimization, meticulous surgical technique and careful management in the postoperative period may reduce the incidence of these complications and influence long-term outcomes.

Although laparoscopic left lateral sectionectomy is increasingly becoming the accepted approach for resection of tumors in hepatic segments II and III, the variations in surgical technique exist.Our technique relies on mobilization of the left lateral sector followed by extracorporeal control of the portal pedicle allowing intermittent occlusion when needed. The parenchyma is thinned, exposing the inflow and outflow allowing application of endoscopic staplers under direct vision for parenchymal transection.Eleven patients underwent left lateral sectionectomy between 2000 and November 2007 and had a median postoperative stay of 3 days. Two patients had to be converted early on.Left lateral sectionectomy using this approach appears to be safe and reproducible, and this technique should be considered for patients with tumors in hepatic segments II and III.

Neoadjuvant chemotherapy is increasingly being used to enlarge the cohort of patients who can be offered hepatic resection for malignancy. However, the impact of these agents on the liver parenchyma itself, and their effects on clinical outcomes following hepatic resection remain unclear. This review identifies patterns of regimen-specific chemotherapy-induced hepatic injury and assesses their impact on outcomes following hepatic resection for colorectal liver metastases (CLM). An electronic search was performed using the MEDLINE (US Library of Congress) database from 1966 to May 2007 to identify relevant articles related to chemotherapy-induced hepatic injury and subsequent outcome following hepatic resection. The use of the combination of 5-flourouracil and leucovorin is linked to the development of hepatic steatosis, and translates into increased postoperative infection rates. A form of non-alcoholic steatohepatitis (NASH) related to chemotherapy and otherwise known as chemotherapy-associated steatohepatitis (CASH) is closely linked to irinotecan-based therapy and is associated with inferior outcomes following hepatic surgery mainly due to hepatic insufficiency and poor regeneration. Data on sinusoidal obstruction syndrome (SOS) following treatment with oxaliplatin are less convincing, but there appears to be an increased risk for intra-operative bleeding and decreased hepatic reserve associated with the presence of SOS. Intra-arterial floxuridine therapy damages the extrahepatic biliary tree in addition to causing parenchymal liver damage, and has been shown to be associated with increased morbidity after hepatic resection. Agent-specific patterns of damage are now being recognized with increasing use of neoadjuvant chemotherapy prior to surgery. The potential benefits and risks of these should be considered on an individual patient basis prior to hepatic resection.

Internal pancreatic fistulae are uncommon sequelae of severe acute pancreatitis. Due to their low prevalence, experience in the management of this condition remains sparse outside specialist centers and management remains controversial. We report our experience with pleuropancreatic fistulae (PPF). Six patients (three males, median age 34 years [range, 32–74 years]) with PPF were managed in our unit over a 24-month period from April 2006 to April 2008. The etiology of pancreatitis was alcohol (four), gallstones (one), and unknown cause (one). All patients had documented pleural effusions with amylase content >1,000 iu/dl. All patients underwent computerized tomography (CT) and magnetic resonance imaging (MRI) cross-sectional scanning to identify the site of ductal disruption. CT alone was able to identify the disruption in four cases and a combination of CT and MRI localized the ductal disruption in all patients. Five of six patients required ERCP and placement of a pancreatic duct (PD) stent. No patient required pancreatic surgery and all patients remain well at a median follow up of 39 weeks. Pleuropancreatic fistulae can present a challenging diagnostic dilemma. A multi-disciplinary approach addressing nutritional support and endotherapy allows successful non-operative resolution within specialist units.

Perivascular epithelioid cells neoplasms (PEComas) constitute a family of rare tumours which have been reported virtually in all anatomic sites. The histological clarification of the malignant potential of these tumours is still problematic despite the proposed risk stratification systems. Li-Fraumeni syndrome (LFS) is caused by a germline mutation in the TP53 tumour suppressor gene. It is a rare but well-characterized cancer predisposition syndrome leading to the development of a variety of different tumour types. To the best of our knowledge, an association between this syndrome and PEComas has not been previously documented. A 24-year-old lady with known LFS presented with two uncertain-in-nature lesions, one within the right part of the liver and one within the upper pole of the right kidney. The patient underwent an uncomplicated open simultaneous right partial nephrectomy and resection of segment 7 of the liver. The morphological and immunohistochemical features of both lesions were of epithelioid angiomyolipoma (PEComa). Although the obvious scenario was that the liver lesion was a metastasis from the renal lesion, the assessment of their malignant potential according to the existing risk stratification systems was rather in favour of two synchronous primary PEComas, pointing out that the histological assessment of malignant potential of PEComas is still problematic.

‘Claudication’ refers to pain experienced in the legs that is brought on by exertion, caused by relative ischaemia of the muscle. Exercise is effective in improving vascular claudication pain and walking distance. Despite this, community-based exercise rehabilitation programmes that are directly available to GPs are almost unknown in the UK. In this pilot study, the authors assess the practicalities of setting up such a programme and evaluate its efficacy. Patients with stable claudication for whom exercise was not contraindicated were enrolled into a twice-weekly exercise programme for up to 8 months (n=20). This was supervised by one of the authors with experience in exercise rehabilitation. Outcome measures included the Six-Minute Walk Test (6MWT) and the Short-Form-36 (SF-36) questionnaire. The average walking distance as measured by the 6MWT increased by 16.3% (P=0.001). There was also a 23.5% increase in the average score of the physical functioning domain of the SF-36 (P=0.007). Community-based exercise rehabilitation for lower limb claudication is safe and effective, with high compliance and attendance rates. Walking distances increase both objectively and subjectively. Patients also become more able to cope with claudication pain and show improvements in their physical function. If these programmes are available to primary care groups, the majority of patients can be managed in the community, reducing the workload of consultant-based hospital services.

Circulating monocyte-derived, tumor-associated macrophages are associated with a poor prognosis for various cancers. Conversely, circulating lymphocytes are the source of tumor-infiltrating lymphocytes, which are associated with an improved prognosis. This study evaluated the prognostic value of the preoperative blood lymphocyte-to-monocyte ratio (LMR) for patients undergoing hepatectomy for liver-only colorectal metastases. This retrospective study examined 140 consecutive patients with liver-only colorectal metastases. Disease-free survival (DFS), post-recurrence survival (PRS), cancer-specific survival (CSS), and overall survival (OS) were analyzed in relation to LMR values using both Kaplan–Meier and multivariate Cox-regression methods. In the multivariate analysis, high LMR (>3) was significantly associated with increased OS [hazard ratio (HR), 2.43; 95 % confidence interval (CI), 1.32–4.48; P = 0.004], CSS (HR 2.15; 95 % CI 1.13–4.10; P = 0.020), and PRS (HR 2.15; 95 % CI 1.15–4.01; P = 0.016) but not with DFS. An LMR lower than 3 may have been associated with decreased CSS and PRS by increasing the rate of multifocal recurrence (P = 0.063). In the multivariate analysis comparing LMR, the neutrophil–lymphocyte ratio, and the platelet-lymphocyte ratio, LMR remained the only significant prognostic variable of CSS. This study identified preoperative LMR as an independent prognostic factor for PRS, CSS, and OS but not for DFS in patients undergoing hepatectomy for liver-only colorectal metastases. In the future, interventions to augment immune function could improve survival for low-LMR patients.

Recent evidence indicates that inflammation is an essential component of pathogenesis and progression of cancer. In this study, we analysed two indexes of systemic inflammation, the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), with disease-free survival (DFS) and overall survival (OS) in liver-only colorectal metastases treated with liver resection following neoadjuvant chemotherapy. In this retrospective study, 140 patients were enroled. The NLR and PLR were calculated on the basis of preoperative blood cell count, and their cut-off levels were determined by applying receiver operating curve analysis. A NLR>2.4 and a PLR>150 were considered to be elevated. DFS and OS were calculated using both Kaplan-Meier and multivariate Cox regression methods. Both high NLR and high PLR were associated with decreased DFS [HR 1.55; 95% confidence interval (CI) 1.03-2.32; P=0.033, and HR 1.78; 95% CI 1.19-2.67; P=0.005, respectively] and OS (HR 2.21; 95% CI 1.24-3.96; P=0.007, and HR 2.90; 95% CI 1.61-5.21; P

Several transthoracic approaches have been described for the surgical management of Boerhaave's syndrome that carry their own morbidity in patients who can be systemically unwell at presentation, and best practice is not established. We introduce a novel transabdominal approach to manage the perforation and spare these patients the trauma of a thoracotomy. Four patients with spontaneous esophageal rupture were managed using a transabdominal approach. Postoperative complications, length of intensive care unit stay, postoperative hospital stay, time to oral intake, and morbidity and mortality were used as outcome measures. After operation, the median intensive care unit stay was 4 days (range, 0–5) in patients who required a median of 10.5 days (range, 6–17) to establish oral intake. One patient required a transthoracic drainage of an empyema and one patient required percutaneous drainage of a mediastinal collection. The median length of stay was 38 days and there was zero mortality. The transabdominal approach is safe and effective for the management of Boerhaave's syndrome and should be considered in the treatment paradigm for this condition. Intrathoracic complications account for postoperative morbidity.

Background Hepatic resections involving the caudate lobe are technically challenging with results from some centers indicating inferior outcomes. We assessed outcomes following hepatic resection for colorectal metastases involving the caudate lobe in a tertiary care center. Methods Operative and oncological data from a prospectively maintained database were analyzed on 687 patients undergoing hepatic resection for colorectal metastases between 1993 and 2006. Patients were analyzed as those with caudate lobe metastases (CLM) and compared with those without caudate lobe involvement (NCLM). Results Fifty-two of 687 patients had metastases involving the caudate lobe (8%). Patients with caudate lobe involvement were more likely to require an extended hepatic resection (75% vs 27%, P =0.001), perioperative blood transfusion (29% vs 14%, P =0.002), have a positive resection margin (57% vs 32%, P =0.001) and stay longer in hospital (12 vs 8days, P =0.001). There was no difference in the complication rates (37% vs 29%) or 30-day mortality between the two groups (2% vs 1%). The median disease free (20months vs 21months), and cancer specific survival (42months vs 59months) were also similar in the CLM and NCLM groups. Conclusions Although caudate lobe involvement adds to the technical complexity of hepatic resection, these patients can be offered long term survival, similar to other patients with hepatic metastases from colorectal cancer.

Liver regeneration: Mechanisms, mysteries and more Background: Liver regeneration remains a fascinating topic, still partly clouded to many as to the exact cellular and molecular mechanisms that bring about this phenomenon. It is an area, therefore, of active research today. This review looks at the recent published reports that have led to a greater understanding of this process. Methods: A database search was carried out on Medline search using the terms liver regeneration with no linguistic limitations from 1966 to 2006. Results: There are two randomized controlled trials on the topic and most data and information have come from experimental studies in animals. Conclusion: Liver regeneration is a complex, tightly controlled process involving many inflammatory cells growth factors and hormones. More information about it is awaited in studies on humans.

Spontaneous pneumomediastinum is an uncommon, self-limiting condition resulting from alveolar rupture in young adults. Because of the ambiguous presentation and the general lack of awareness of this condition, its diagnosis is often delayed, missed, or confused with spontaneous esophageal perforation. We report our experience of treating six patients who were referred to our unit with vomiting-induced pneumomediastinum, subcutaneous emphysema, and an initial diagnosis of spontaneous esophageal perforation. Ultimately, we diagnosed spontaneous pneumomediastinum in all six patients, who recovered uneventfully without any surgical intervention. We review the literature with particular emphasis on differentiating spontaneous pneumomediastinum from spontaneous esophageal perforation.

The majority of patients with upper gastrointestinal (UGI) tract malignancy present at a stage where cure of disease is not possible. The aim of treatment in these patients is effective palliation. Various interventions have been described for the palliation of biliary and gastric outlet obstruction including open surgery, endoscopic and transparietal stent placement. Laparoscopic bypass appears to have the advantage of decreased postoperative pain and shorter hospital stay as well as offer effective palliation. The aim of this study was to assess the safety and efficacy of laparoscopic bypass in patients with incurable UGI tract malignancy.Between August 2000 and April 2002 laparoscopic gastric and biliary bypass concurrently or alone was attempted in 19 consecutive patients with unresectable carcinoma of the head of the pancreas, adenocarcinoma of the stomach, cholangiocarcinoma of the distal common bile duct, or adenocarcinoma of the duodenum. The operative time, length of postoperative stay, complications, and the effectiveness of the procedure in terms of the ability to sustain oral nutrition and or the relief of obstructive jaundice were recorded and used as outcome measures.Laparoscopic bypass was successful in 18 out of 19 cases. The mean operative time for a single bypass was 164 minutes while the average postoperative hospital stay was 11 days. All patients were able to sustain oral nutrition during the course of their hospital stay and or had effective relief from their obstructive jaundice. Two patients died from procedure unrelated causes within 30 days of the operation.Laparoscopic bypass appears to be a safe and effective means of palliation for patients with unresectable UGI tract tumors and should replace open surgical palliation in this group of patients.

11 pH Associates Limited, Marlow, UK Background: Patient survival in metastatic colorectal cancer (mCRC) can be improved if patients with metastases confined to the liver are able to undergo liver resection. Resectability of liver metastases was improved in clinical trials of downsizing with chemotherapy plus cetuximab. This study describes the liver resection rate achieved in normal UK clinical practice using chemotherapy plus cetuximab in patients whose tumours were originally deemed inoperable by a Hepatobiliary Multi-disciplinary Team (HPBMDT). Methods: A multi-centre retrospective observational study was conducted in 7 UK hospitals with specialised liver surgical services. Included patients had mCRC with metastases confined to the liver, defined locally as unresectable at first review by the

ObjectiveThe aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours.MethodsFrom February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database.ResultsResections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients.ConclusionsAggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.