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The article presents a study which examines the effects of computed tomography (CT)-based follow-up for the diagnosis of resectable disease after being subjected to colorectal liver metastases (CRLM) surgery. An overview of the methodology used for the study is provided, along with information on the resection of CRLM. Results showed that the 3-monthly surveillance intervals for the initial year after hepatic resection has a tendency to impact survival in individuals with recurrence applicable for resection.

Abstract: Introduction: Hepatocellular carcinoma (HCC) is currently the fifth most common neoplasm worldwide. The only therapies which are capable of providing cure are hepatic resection and liver transplantation. Results from either resection or transplantation show 5-year survival rates of up to 70% in selected patients. Patient assessment is key to selecting candidates for surgery be it resection or transplantation. Methods: A search was performed of the English Medline database for the period 1997–2006 using the MeSH headings: hepatocellular carcinoma, liver resection, and liver transplantation, with the main analysis concentrated on survival data for all patients undergoing resection or transplantation. Results: There is a large variation in the mortality and recurrence rate following resection/transplantation due to differences in definition in different series. The median perioperative (30 day/in-hospital) mortality rate following resection was a median of 4.7%. The median 1, 3 and 5 year overall survival rates were 80.1%, 55% and 37.1%, respectively. The disease-free survivals at identical time intervals were 64%, 38% and 27%. The median 30 day mortality following liver transplant was 4.7% and the median 3-month mortality was 13.3%. The median overall 1, 3, and 5-year survival rates were 80.9%, 70.2% and 62%, respectively, whilst the disease-free survivals at identical time intervals were 79%, 62.5% and 54.5%. Several risk factors for overall and/or disease-free survival following resection and transplantation were found in those papers where a multivariate analysis was included. Discussion: A possible algorithm would be to perform resection for patients with preserved liver function and offer transplantation to those of Child–Pugh status B or C who fit within Milan criteria. If recurrence occurred after resection or underlying liver disease progresses, salvage transplants may be performed. Conclusion: The current evidence base for resection and transplantation in the treatment of HCC is inadequate to provide a definite answer as to which is optimal therapy and a randomised controlled trial to compare the outcomes of resection and transplantation is now required. [Copyright &y& Elsevier]

Abstract: Introduction: Carcinoma of the ampulla of Vater is said to carry a significantly better prognosis than pancreatic ductal adenocarcinomas arising in the pancreatic head. However, it is uncertain as to whether this is due to the fact that they have differing oncological characteristics or simply an earlier presentation as a result of the exophytic morphology of ampullary lesions causing obstruction of the bile ducts. Methods: All patients undergoing pancreaticoduodenectomy between January 1998 and December 2004 were identified from a prospectively maintained database. Patients with a pathologically confirmed ampullary (AMP) tumour were compared to those with a carcinoma of the head of the pancreas (HOP). Tumour characteristics including size, stage and degree of differentiation were analysed as were survival data. Results: 71 AMP and 144 HOP tumours were resected during the period studied and had full histology reports available for assessment. The median diameter of the AMP tumours was significantly less than those of the HOP (2cm vs. 3cm; p =0.04). The T stage distribution differed significantly between the AMP and HOP tumours in favour of the former (Stages I – 10 vs. 0 (p =0.03); II – 29 vs. 13 (p =0.04); III – 25 vs. 121 (p =0.01); IV – 7 vs. 10). The number of resection specimens with positive lymph nodes was lower in the AMP group (31 vs. 121; p =0.03) as was the prevalence of vascular invasion (33 vs. 114; p =0.006) and neural invasion (23 vs. 134; p =0.009). There was no difference in the degree of differentiation of the AMP and HOP tumours. The 5-year survival rates were significantly better in the AMP group at 60% vs. 20% (p =0.008). Subdivision of AMP carcinoma into polypoid (60%) and ulcerating (40%) lesions revealed a non-significant survival advantage in favour of polypoid tumours at (64% vs. 60%; p =0.07) at 5 years. Conclusions: The outcome of resection for AMP is significantly better than for pancreatic ductal adenocarcinomas arising in the periampullary region. Although the anatomical position of AMP tumours may contribute to this survival advantage, the HOP tumours exhibit more adverse histological features suggesting that they are different diseases and hence the difference in survival. [Copyright &y& Elsevier]

Background: Standard evaluation of patients undergoing hepatic surgery has been through radiological and quantitative determination of liver function. As more complex and extensive surgery is now being performed, often in the presence of cirrhosis/fibrosis or following administration of chemotherapy, it is questioned whether additional assessment may be required prior to embarking on such surgery. The aim of this review was to determine the current knowledge base in relation to the performance of quantitative assessment of hepatic function both pre- and post-operatively in patients undergoing hepatic resectional surgery and liver transplantation.Methods: An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles with cross-referencing of all identified papers to ensure full literature capture.Results and Conclusions: The review has identified a number of different methods of dynamically assessing hepatic function, the most frequently performed being through the use of indocyanine green clearance. With the recent and further anticipated developments in hepatic resectional surgery, it is likely that quantitative assessment will become more widely practiced in order to reduce post-operative hepatic failure and improve outcome. [ABSTRACT FROM AUTHOR]

Background and Aims: 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).Patients: 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.Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

Background. Surgery for colorectal liver metastases (CRLM) can be expected to be associated with a significant rate of thromboembolic complications due to the performance of long-duration oncologic resections in patients aged 60 years. Aims. To determine the prevalence of clinically significant thrombotic complications, including deep venous thrombosis (DVT) and pulmonary embolus (PE), in a contemporary series of patients undergoing resection of CRLM with standard prophylaxis. Material and methods. A prospectively maintained database identified patients undergoing resection of CRLM from January 2000 to March 2007 and highlighted those developing thromboembolic complications. In addition, the radiology department database was reviewed to ensure that clinically suspicious thromboses had been confirmed radiologically by ultrasound in the case of DVT or computed tomography for PEs. Results. During the period of the study, 523 patients (336 M and 187 F) with a mean age of 65 years underwent resection. A major hepatectomy was performed in 59.9%. One or more complications were seen in 45.1% (n=236) of patients. Thrombotic complications were seen in 11 (2.1%) patients: DVT alone (n=4) and PE (n=7). Eight of 11 thrombotic complications occurred in patients undergoing major hepatectomy, 4 of which were trisectionectomies. Patients were anti-coagulated and there were no mortalities. Conclusions. The symptomatic thromboembolic complication rate was lower in this cohort than may be expected in patients undergoing non-hepatic abdominal surgery. It is uncertain whether this is due entirely to effective prophylaxis or to a combination of treatment and a natural anti-coagulant state following hepatic resection. [ABSTRACT FROM AUTHOR]

Paraoesophageal hernias are an uncommon but important diaphragmatic defect due to a high prevalence of associated complications. The advent of laparoscopic surgery has popularised the surgical management of this condition, although the optimal technique has yet to be defined. The aim of this cohort study was to assess the necessity of an anti-reflux procedure in addition to the crural repair. Details of all patients undergoing laparoscopic paraoesophageal hernia repair were collected prospectively paying particular attention to the details of the operative procedure and outcome, including the development of early complications. All patients were followed for six months and symptoms related to hernia recurrence or technical failure including dysphagia and reflux were noted. Twenty-three consecutive patients underwent laparoscopic paraoesophageal hernia repair. The first 11 patients (Group 1) routinely underwent an additional anti-reflux procedure, whereas the later cohort (Group 2) did not (chi-squared P < 0.05). At six months, nine of eleven patients in Group 1 reported dysphagia, in two cases requiring dilatation, but this complication was not seen in those in Group 2. Two patients reported reflux at six-month follow-up; this was controlled in both cases by a low dose of a proton pump inhibitor. Laparoscopic repair of paraoesophageal hernias is an effective treatment with excellent short-term results and no recurrences. Our experience would suggest that an anti-reflux procedure is not always indicated and may indeed be detrimental to symptomatic outcome. [ABSTRACT FROM AUTHOR]

Abstract: Aims: The aim of this article is to review the current state of knowledge in relation to the development of chemotherapy associated steatohepatitis (CASH) and sinusoidal obstruction syndrome (SOS) occurring following the administration of irinotecan and oxaliplatin respectively to patients with colorectal liver metastases and also to highlight potential concerns relating to other new agents. Methods: An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles related to the incidence, aetiology, pathology and effects of CASH and SOS outcome in patients undergoing hepatic resection. Results: CASH and SOS are relatively common findings in liver resection specimens following the administration of irinotecan and oxaliplatin-based regimes being reported in up to 50% and 20% of cases respectively. Whilst the aetiology and pathological changes are well-described, the relationship between the presence of these pathologies and outcomes is less well defined. The data in relation to SOS following oxaliplatin is limited but there may be an increased morbidity associated with the presence of SOS. There is significantly more evidence that the presence of CASH is associated with an increased morbidity and possibly mortality following hepatic resection as a result of the development of liver failure. Further studies are required to clarify these early observations. Conclusions: The frequent identification of distinct pathological entities in association with oxaliplatin and irinotecan chemotherapy means that patients undergoing liver resection following treatment with these agents should be carefully monitored to accurately determine the morbidity and mortality attributable to the use of these agents. Furthermore, additional studies are required to clarify risk factors for the development of CASH and SOS so that certain regimens can be avoided in at risk populations thus reducing hepatic damage and increasing the chances of cure and survival following liver resection. [Copyright &y& Elsevier]

Background: Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. Objective: We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. Material and methods: All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. Results: Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p=<0.0001). Conclusion: Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered. [ABSTRACT FROM AUTHOR]

Introduction. Gastric outlet obstruction (GOO) is a frequent feature of advanced pancreatic carcinoma. Self-expandable metal stents (SEMS) allow the condition to be managed outside by endoscopy rather than surgical bypass. The aim of this study is to report our experience in a district general hospital with SEMS for palliation of pancreatic carcinoma-related GOO. Patients and methods. All patients admitted with or developing GOO secondary to pancreatic adenocarcinoma between January 2004 and December 2005 were identified. Notes were retrieved to determine the efficacy of stenting including: complications of the procedure, length of stay, readmissions and long-term patency. Results. Of 39 new cases of pancreatic cancer, 9 patients presented with (n=6) or developed (n=3) duodenal obstruction. In one patient, previous gastric surgery restricted access. Stenting was attempted in 8 patients (4 M and 4 F) with a mean age of 63 years (range 42-76 years). In one case, the duodenal invasion was too extensive to allow passage of the guide-wire and open bypass was performed. Stenting was successful in the remaining seven patients with no early complications. The median hospital stay post-procedure was 7 days (range 5-11 days). One patient was re-admitted after 11 weeks with recurrent duodenal obstruction and a second stent was placed. The median survival post-stenting was 10 weeks (range 3-28 weeks). Conclusions. SEMS allows patients to leave hospital quickly and return to daily activities, albeit for the short term. The procedure requires an experienced interventional endoscopist but can be accomplished safely in the DGH setting. [ABSTRACT FROM AUTHOR]

Aim: To report the prevalence and outcome of cholangiocarcinoma arising in primary sclerosing cholangitis for a British tertiary referral centre. Methods: All patients diagnosed with primary sclerosing cholangitis and concurrent cholangiocarcinoma were identified from a prospectively maintained departmental database, and the mode of presentation, management and outcome were determined. Results: Of 370 patients with primary sclerosing cholangitis, 48 patients (13%) were diagnosed with a cholangiocarcinoma within a median time of 0.51 months (range: 0–73.12) from presentation to the unit. Mode of presentation included: inoperable tumours (n = 14); incidental findings in transplant hepatectomy specimens (n = 13); primary sclerosing cholangitis follow-up (n = 9); transplant work-up (n = 5); transplant waiting list (n = 5); suspected tumour confirmed at transplant (n = 1), and incidental finding at cholecystectomy (n = 1). The diagnosis was confirmed by: radiology-guided biopsy (n = 27); MRI (n = 3); CT (n = 2); laparoscopy or laparotomy (n = 2), and frozen section at transplant (n = 1). Management consisted of: transplantation (n = 14, including 1 abandoned); hepatic resection (n = 8), and palliation through stenting (n = 26). The overall median survival of the cohort was 4.9 months (range: 0.09–104.5). Median survival ranged from 2.6 months (range: 0.09–35.3) for palliation to 7.6 months (range: 0.6–99.6) for transplantation and 52.8 months (range: 3.7–104.5) for resection. There was no difference in survival between the transplant and resection groups (p = 0.14). Conclusions: Cholangiocarcinoma is a common finding in primary sclerosing cholangitis and regular screening of this cohort of patients at referring centres is advocated to detect early tumours, as surgical treatment at an early stage offers significantly better outcomes for this cohort of patients. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aims. To determine the prevalence of bactibilia in patients undergoing cholecystectomy and to relate the presence or absence of organisms to the preoperative and postoperative course. Patients and methods. Patients undergoing cholecystectomy under the care of a single consultant surgeon during a continuous 5-year period were identified from a prospectively maintained departmental database. Symptoms, clinical signs, findings of investigations, details of treatment and postoperative care were noted. Risk factors for bactibilia (acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age > 70 years) were documented. Patients were divided according to the presence (B + ) or absence (B-) of bacteria on culture of their bile. Results. In all, 128/180 (70%) of cholecystectomies had full data available for analysis. Bacteria were identified in the bile of 20 (15.6%) patients (B+ group). The B+ group was significantly older at 63.78±9.7 versus 61.62±13.9 (p<0.05) and contained significantly fewer females than the B- group (p<0.05). All 20 patients (100%) in the B+ group had ≥ 1 risk factor, while these factors were present in only 29/108 (30.3%) of patients in the B- group (p<0.05). The overall incidence of infective complications was 20% in the B+ group compared with 0.9% in the B- group (p<0.05) and the bile-related infections were higher in the B+ group (p<0.05). Conclusions. The study demonstrated that while patients with complicated gallstone disease frequently exhibit bactibilia, patients with uncomplicated cholelithiasis have aseptic bile. The findings would suggest that prophylactic antibiotics should be limited to patients with risk factors for bactibilia. [ABSTRACT FROM AUTHOR]

Aim: To document the prevalence and to evaluate the management strategies of haemorrhagic complications following pancreaticoduodenectomy (PD). Methods: All patients who underwent PD from 1/2000 to 10/2005 and experienced at least one episode of haemorrhage during the 30 first days postoperatively were recorded. Etiology of haemorrhage, treatment strategy and mortality rate were recorded and analyzed. Results: A total of 362 patients underwent PD during this period and 32 (8.8%) had haemorrhage postoperatively of whom 15 died (47% mortality rate). Primary intraluminal haemorrhage was recorded in 13 patients, primary intra-abdominal haemorrhage in 5 patients and secondary haemorrhage in 14 patients. Successful management of haemorrhage with angioembilization occurred in 2 patients in the study group. Statistical analysis revealed sepsis and sentinel bleed as risk factors for post-PD haemorrhage and pancreatic leak and sentinel bleed as risk factors for secondary haemorrhage (p < 0.05). Conclusions: Haemorrhage after PD is a life-threatening complication. Sepsis, pancreatic leak, and sentinel bleed are statistical significant factors predicting post-PD haemorrhage. Sentinel bleed is not statistically significant associated with postoperative mortality, but with the onset of secondary haemorrhage. The effectiveness of therapeutic angioembolization was not demonstrated in our study. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Unlike in Japan, autoimmune pancreatitis is uncommon in the Western world, particularly in Europe. We report the first case of a Caucasian male with typical features of autoimmune pancreatitis in the UK. Recognizing autoimmune pancreatitis as a new clinical entity in Europe will change the management of many patients who have been labelled as having acute or chronic pancreatitis. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to assess whether screening of popliteal arteries in patients undergoing ultrasound screening of their abdominal aortas was worthwhile. Methods: All male patients undergoing ultrasound screening for abdominal aortic aneurysm (AAA) during the period February 2000 to June 2002 were offered scanning of their popliteal arteries. All scans were performed by a single, trained operator using a Sonosite 180. Results: Four hundred and forty-nine patients underwent screening and thus 898 popliteal arteries were assessed. The mean aortic diameter was 2.1 standard deviations (SD) 0.5cm and the upper limit of normal (2 SD) was 2.7cm. The mean diameter of the popliteal arteries was 0.74 SD 0.11 and the upper limit of normal was 0.96cm. Thirty patients had aortic diameters greater than 2.5cm (ectatic or aneurysmal aortas) but based on a popliteal diameter of 2cm, no popliteal aneurysms were detected. However, 39 (4.3%) popliteal arteries measured ≥1cm (>mean+2 SD); 3/60 (5%) in the ectatic/AAA subgroup and 36/838 (4.3%) in the non-AAA subgroup. Conclusions: This study has shown that, using conventional definitions, the imaging of popliteal arteries during screening for AAAs does not detect any popliteal aneurysms and is thus of limited value. However, if a definition of popliteal aneurysm of ≥1cm (based on mean+2 SD) is used then 39/898 (4.3%) of arteries would be regarded as having abnormal diameters and may require surveillance. [Copyright &y& Elsevier]

Background: Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years. Methods: A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded. Results: Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight. Conclusion: SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained [ABSTRACT FROM AUTHOR]

Examines the sequential changes in plasma selenium concentration after cadaveric renal transplantation. Relationship between the selenium levels and risk factors for chronic graft nephropathy (CGN); Role of antioxidant deficiency in the pathogenesis of clinically apparent CGN; Reason behind the low plasma selenium concentrations in patients with CGN than those with well functioning grafts.

Aims Histological appearances indistinguishable from Crohn's disease have been described in patients undergoing sigmoid colectomy for complicated diverticular disease. To investigate whether this finding represents coincidental dual pathology or merely a granulomatous colitis confined to the diverticular segment, we undertook clinical follow-up of affected patients. Methods and results Eight patients (median age 64 years, four males) whose sigmoid colectomy specimens showed acute diverticulitis and granulomatous inflammation were identified. All had a pre-operative diagnosis of diverticular disease and no previous evidence of Crohn's disease. Non-caseating epithelioid granulomas, unrelated to foreign material and usually unrelated to inflamed diverticula were present in the bowel wall of seven cases and in the regional lymph nodes of five. Three had granulomatous vasculitis and two had granulomas in ‘background’ mucosa. Mural lymphoid aggregates were identified in all cases. However, fissuring ulcers distinct from inflamed diverticula were not identified. On median follow-up of 51 months (range 18–112 months) none of the patients developed evidence of chronic inflammatory bowel disease. Three had died from unrelated causes. Conclusions Granulomatous inflammation appears to be part of a spectrum of sigmoid diverticulitis. In this setting, caution should be exercised to avoid an inappropriate diagnosis of Crohn's disease. [ABSTRACT FROM AUTHOR]