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Background: Recently, statins have been associated with improved survival in certain cancers. The aim of this study was to evaluate the impact of statins on the outcome of patients undergoing surgery for pancreatic cancer. In addition, the effect of statins on the histopathological characteristics of the disease was assessed., Methods: A retrospective review of the prospectively maintained hepato-pancreatico-biliary database was performed and patients with pancreatic cancer who underwent surgery between January 2014 and December 2017 were included. Statistical analysis was performed to assess the impact of statins on histopathological characteristics and survival outcome., Results: A total of 151 patients were included, of whom 71 underwent pancreatic resections and 80 underwent trial dissection and bypass procedures. In the operated group, 20 patients were on statin therapy preoperatively. With respect to disease-free survival, tumour size (P = 0.023) and lymphatic invasion (P = 0.015) were significant variables on univariate analysis. Gender (P = 0.022), adjuvant chemotherapy (P < 0.001), lymphatic invasion (P = 0.021) and tumour size (P = 0.041) were significant variables on univariate analysis with respect to overall survival. Multivariate analysis identified adjuvant chemotherapy as the only independent predictor of overall survival (P < 0.001). No correlations between the use of statins and the histopathological characteristics were identified., Conclusion: Adjuvant chemotherapy is an independent predictor of overall survival in patients undergoing surgery for pancreatic cancer. Statin therapy does not influence survival outcomes and histopathological characteristics following surgery for pancreatic cancer., (© 2019 Royal Australasian College of Surgeons.)

Purpose The objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy. Methods Patients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed.  Results A total of 149 patients were included. Cholecystitis was the most common diagnosis ( n  = 86, 57.7%), followed by acute pancreatitis ( n  = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as "difficult". The overall morbidity rate was 15.4% ( n  = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years ( p  = 0.012), underlying diagnosis ( p  = 0.010), presence of heart rate >90 ( p  = 0.027), and an elevated pre-surgery CRP >100 ( p  < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy ( p  = 0.041). Conclusions An elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting., Competing Interests: The authors have declared that no competing interests exist.

Background: Socioeconomic inequalities in colorectal cancer (CRC) survival are well recognised. The aim of this study was to describe the impact of socioeconomic deprivation on survival in patients with synchronous CRC liver-limited metastases, and to investigate if any survival inequalities are explained by differences in liver resection rates., Methods: Patients in the National Bowel Cancer Audit diagnosed with CRC between 2010 and 2016 in the English National Health Service were included. Linked Hospital Episode Statistics data were used to identify the presence of liver metastases and whether a liver resection had been performed. Multivariable random-effects logistic regression was used to estimate the odds ratio (OR) of liver resection by Index of Multiple Deprivation (IMD) quintile. Cox-proportional hazards model was used to compare 3-year survival., Results: 13,656 patients were included, of whom 2213 (16.2%) underwent liver resection. Patients in the least deprived IMD quintile were more likely to undergo liver resection than those in the most deprived quintile (adjusted OR 1.42, 95% confidence interval (CI) 1.18-1.70). Patients in the least deprived quintile had better 3-year survival (least deprived vs. most deprived quintile, 22.3% vs. 17.4%; adjusted hazard ratio (HR) 1.20, 1.11-1.30). Adjusting for liver resection attenuated, but did not remove, this effect. There was no difference in survival between IMD quintile when restricted to patients who underwent liver resection (adjusted HR 0.97, 0.76-1.23)., Conclusions: Deprived CRC patients with synchronous liver-limited metastases have worse survival than more affluent patients. Lower rates of liver resection in more deprived patients is a contributory factor., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Coding inaccuracies in surgery misrepresent the productivity of hospitals and outcome data of surgeons. The aim of this study was to audit the extent of coding inaccuracies in hepato-pancreato-biliary (HPB) surgery and assess the financial impact of introducing a coding proforma., Methods: Coding of patients who underwent elective HPB surgery over a 3-month period was audited. Codes were based on International Classification of Diseases 10 and Office of Population and Census Surveys-4 codes. A coding proforma was introduced and assessed. New human resource group codes were re-assigned and new tariffs calculated. A cost analysis was also performed., Results: Prior to the introduction of the coding proforma, 42.0% of patients had the incorrect diagnosis and 48.5% had missing co-morbidities. In addition, 14.5% of primary procedures were incorrect and 37.6% had additional procedures that were not coded for at all. Following the introduction of the coding proforma, there was a 27.5% improvement in the accuracy of primary diagnosis (P < 0.001) and 21% improvement in co-morbidities (P = 0.002). There was a 7.2% improvement in the accuracy of coding primary procedures (P = not significant) and a 21% improvement in the accuracy of coding of additional procedures (P < 0.001). Financial loss as a result of coding inaccuracy over our 3-month study period was £56 073 with an estimated annual loss of £228 292., Conclusion: Coding in HPB surgery is prone to coding inaccuracies due to the complex nature of HPB surgery and the patient case-mix. A specialized coding proforma completed 'in theatre' significantly improves the accuracy of coding and prevents loss of income., (© 2017 Royal Australasian College of Surgeons.)

Aim: To evaluate the impact of anti-platelet therapy on the outcomes of patients undergoing liver resection for CRLM. Secondary aim was to determine whether anti-platelet therapy influenced histo-pathological changes in CRLM., Methods: Patients treated with liver resection for CRLM were identified from a prospectively maintained hepatobiliary database during an 11-year period. Collated data included demographics, primary tumour treatment, surgical data, histopathology analysis and clinical outcome., Results: 454 patients that underwent primary hepatic resections for CRLM were included. 60 patients were on anti-platelet therapy. 241 patients developed recurrent disease and 131 patients have died. Multi-variate analysis identified 4 independent predictors of disease-free survival: tumour number; tumour size; peri-neural invasion; and resection margin. The presence of peri-neural invasion and multiple hepatic metastases were independent predictors of poorer overall survival on multi-variate analysis. Uni-variate analysis showed that the use of anti-platelet therapy was associated with larger tumour size (p=0.031) and vascular invasion (p=0.023)., Conclusion: Anti-platelet therapy does not affect the survival outcome in patients with CRLM following liver resection. Anti-platelet therapy is associated with larger liver metastases and vascular invasion on histo-pathological analysis., Synopsis: A large retrospective study looking at outcomes of patients taking pre operative anti platelet therapy who have undergone liver resection for colorectal liver metastases., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the relationship between electrical stimulation administered to patients undergoing bilateral electroconvulsive therapy (ECT) and subsequent measures of cognitive function and depression severity., Methods: Stimulus dose titrated patients receiving bilateral ECT were assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB) Spatial Recognition Memory test and Montgomery Asberg Depression Rating Scale (MADRS) at baseline, after 4 ECT treatments and on course completion. Changes in CANTAB and MADRS scores were assessed in relation to electrical dosage, initial stimulus dose, and demographic variables using linear mixed models., Results: Data pertained to 143 patients (mean age, 56.85 [SD, 14.94], 43% male). Median change in CANTAB score was -10% (-20% to 5%) after 4 ECT treatments and -10% (-20% to 5%) at course completion. Median change in MADRS score was -22 (-33 to -13) after 4 ECT treatments and -14 (-25 to -7) at course completion. Electrical dosage had no effect on CANTAB or MADRS change scores either after 4 treatments or course completion. Improvement in CANTAB score at end of course was associated with female sex (P < 0.05), higher intelligence quotient (P = 0.01), and age. After 4 treatments, improvement in CANTAB score was associated with younger age (P < 0.001) and higher intelligence quotient (P < 0.01). Improved MADRS score at course completion was associated with older age (P < 0.001 at end of course and after 4 treatments)., Conclusions: Electroconvulsive therapy has significant antidepressant and cognitive effects which are not associated with the total electrical dose administered. Other, unalterable variables, such as age and sex, have an influence on these effects.

Background: To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients., Methods: Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords 'pancreatic cancer', 'resectability', 'staging', 'laparoscopy', and 'Whipple's procedure'., Results: Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL., Conclusion: The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size., (Copyright © 2015 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Aims: The high objective response rate to cetuximab along with chemotherapy in patients with colorectal liver metastases makes it an effective downsizing protocol to facilitate surgery in those with initially unresectable disease. Adoption of this strategy has been variable in the UK. A retrospective observational study was conducted in 7 UK specialist liver surgical centres to describe the liver resection rate following a downsizing protocol of cetuximab and chemotherapy and to evaluate the quality and efficiency of processes by which the treatment was provided., Methods: Data were collected in 2012 by reviewing medical records of patients with colorectal metastases confined to the liver, defined as unresectable without downsizing therapy at first review by a specialist Multi Disciplinary Team (MDT)., Results: Sixty patients were included; 29 (48%) underwent liver resection following cetuximab and chemotherapy. Of the 29, 17 (59% or 28% of all patients) achieved R0 resection and 7 (24% or 12% of all patients) R1 resection. All treated patients were KRAS wild-type., Conclusion: In specialist liver surgical centres, where patients are evaluated for liver resection, optimal management by MDT using KRAS testing, cetuximab and chemotherapy results in a 28% R0 resection rate in patients with initially unresectable colorectal cancer liver metastases., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The aim of this study was to identify prognostic factors, particularly pathological variables, that influence disease-free and overall survival following resection for colorectal liver metastases (CRLM)., Methods: Patients undergoing CRLM resection from January 2005 to December 2011 were included. Data analysed included information on demographics, laboratory results, operative findings, histopathological features and survival., Results: A total of 259 patients were included. Of these, 138 (53.3%) patients developed recurrent disease, of which 95 died. The median length of follow-up in the remaining patients was 28 months (range: 12-96 months). There were significant associations between recurrence and higher tumour number (P = 0.002), presence of perineural invasion (P = 0.009) and positive margin (R1) resection (P = 0.002). Multivariate analysis showed all three prognostic factors to be independent predictors of disease-free survival. Significantly poorer overall survival after hepatic resection for CRLM was observed in patients undergoing hemi-hepatectomy or more radical resection (P = 0.021), patients with a higher number of tumours (P = 0.024) and patients with perineural invasion (P < 0.001). Multivariate analysis showed perineural invasion to be the only independent predictor of overall survival., Conclusions: The presence of perineural invasion, multiple tumours and an R1 margin were associated with recurrent disease. Perineural invasion was also an independent prognostic factor with respect to overall survival., (© 2014 International Hepato-Pancreato-Biliary Association.)

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., (Copyright © 2013. Published by Elsevier Ltd.)

Background: Focal nodular hyperplasia (FNH) is a common benign disease of the liver with no recognized potential for malignant transformation. The term describes an entity of lobular proliferation of normally differentiated hepatocytes, frequently around a central fibrous scar. Two key issues influence surgical decision making in FNH: diagnostic certainty, and symptomatic assessment., Methods: A systematic review of studies reporting hepatic resections of FNH was performed. Indications and outcomes in adult populations were examined with a focus on diagnostic workup, patient selection and operative mortality and morbidity., Results: Diagnostic modalities in the majority of studies involved ultrasound and computed tomography. Fewer than half employed magnetic resonance imaging (MRI). In instances in which MRI was not available, diagnostic accuracy was inferior., Conclusions: Percutaneous biopsy should be avoided to prevent the risk for tumour seeding. Patients presenting with asymptomatic definitive FNH can be safely managed conservatively. In symptomatic patients surgical resection is a safe and effective treatment for which acceptable rates of morbidity (14%) and zero mortality are reported. However, evidence of symptom resolution is reported with conservative strategies. Diagnostic uncertainty remains the principal valid indication for FNH resection, but only in patients in whom contrast-enhanced MRI forms part of preoperative assessment., (© 2013 International Hepato-Pancreato-Biliary Association.)

Background: To date, there is limited data on the liver-first approach in the management of colorectal liver metastases (CRLM). The aim of the study was to assess the outcomes of the liver-first approach for patients with synchronous CRLM in two tertiary referral centers., Methods: Patients with stage IV colorectal cancer selected for the liver-first approach from January 2009 to December 2012 in two tertiary referral centers were included. Data collated included demographics, chemotherapy, operative findings, histo-pathological features, and survival., Results: Thirty-seven patients with synchronous CRLM were considered for the liver-first approach. Twenty-five patients had rectal cancer. All patients underwent induction chemotherapy. Thirty patients underwent hepatic resections with no post-operative deaths. Following liver resection, five patients failed to proceed to colorectal resection and one patient had complete response to chemo-radiotherapy. Of the 25 patients that completed the liver-first approach, 13 patients had recurrent disease, of which 12 patients died. The overall 1- and 3-year survival rates were 65.9% and 30.4%, respectively., Conclusion: The liver-first approach is a feasible strategy for patients with synchronous CRLM and may improve survival in selected patients. The selection of patients should be incorporated in a multidisciplinary approach to achieve the best possible outcomes., (© 2013 Wiley Periodicals, Inc.)

Background: To review the outcomes of patients with synchronous colorectal liver metastases (CRLM) treated by the "liver-first" approach., Methods: Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords "colorectal cancer", "liver-first", "reverse strategy", "liver metastases", "liver resection" and "hepatectomy"., Results: There have been four retrospective studies that have reported the outcomes of patients with synchronous CRLM following the reverse strategy. The number of patients included ranged from 16 to 27. One study included patients with advanced rectal cancer and synchronous liver metastases only. None of the studies defined resectability for the CRLM. Overall, the morbidity and mortality rates were low. The recurrence rate ranged from 25 to 70 %. One study did not report survival data, and the overall 5 year survival ranged from 31 to 41 %., Conclusion: The "liver-first" approach may be beneficial to a selected group of patients with synchronous CRLM. Patient selection is likely to be determined by their response to down-staging chemotherapy with or without biological agents.

Background: To review the outcomes following cetuximab therapy in patients with metastatic colorectal cancer., Methods: Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords "colorectal cancer", "cetuximab", "liver metastases", "liver resection" and "hepatectomy"., Results: Cetuximab was first used in the palliative setting and an increase in response rates were seen, however with no improvement in overall survival. Published data have observed that cetuximab may be beneficial as part of a down-staging programme. The addition of cetuximab to chemotherapy regimens in patients with KRAS wild-type colorectal cancer has been shown to increase the response rates and the number of patients being down-staged and offered potentially curative resection. The OPUS and CRYSTAL trials observed good response rates following the addition of cetuximab but low resection rates. The CELIM and POCHER studies reported higher resection rates due to better patient selection and study design. However, the majority of published studies tend to report minimal surgical data and lack short- and long-term outcomes., Conclusion: The use of cetuximab to conventional chemotherapy regimens may improve the efficacy of down-staging programmes, leading to more patients being offered potentially curative resection., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: The amount of tissue that is ablated or necrosed at the line of parenchymal transection is of clinical significance in the interpretation of resection margin status following hepatic resection. The aim of this study was to define the extent of parenchymal ablation and necrosis in liver tissue using the Harmonic Scalpel, the LigaSure, the Cavitron Ultrasonic Surgical Aspirator (CUSA) and the Aquamantys dissector ex vivo., Methods: Mounted blocks of non-perfused bovine liver were transected using the Harmonic Scalpel, LigaSure, CUSA and Aquamantys devices. Outcome measures included parenchymal ablation (ablation band widths and weights) and tissue necrosis band widths along the line of transection. Each experiment was replicated five times., Results: All devices were associated with parenchymal ablation (Harmonic Scalpel, 4.73 ± 1.62 mm; LigaSure, 4.55 ± 2.02 mm; CUSA, 7.16 ± 2.87 mm; Aquamantys, 4.75 ± 1.43 mm) and tissue necrosis (Harmonic Scalpel, 1.07 ± 0.46 mm; LigaSure, 1.36 ± 0.36 mm; CUSA, 0.81 ± 0.21 mm; Aquamantys, 0.81 ± 0.36 mm)., Conclusions: The Harmonic Scalpel, LigaSure, CUSA and Aquamantys devices were associated with bands of tissue loss along the hepatic parenchymal transection line in this benchtop cadaveric model. This should be taken into account in the interpretation of resection margin status following liver resection., (© 2012 International Hepato-Pancreato-Biliary Association.)

Objectives: To assess the role of serum amylase and lipase in the diagnosis of acute pancreatitis. Secondary aims were to perform a cost analysis of these enzyme assays in patients admitted to the surgical admissions unit., Design: Cohort study., Setting: Secondary care., Participants: Patients admitted with pancreatitis to the acute surgical admissions unit from January to December 2010 were included in the study., Methods: Data collated included demographics, laboratory results and aetiology. The cost of measuring a single enzyme assay was £0.69 and both assays were £0.99., Results: Of the 151 patients included, 117 patients had acute pancreatitis with gallstones (n=51) as the most common cause. The majority of patients with acute pancreatitis had raised levels of both amylase and lipase. Raised lipase levels only were observed in additional 12% and 23% of patients with gallstone-induced and alcohol-induced pancreatitis, respectively. Overall, raised lipase levels were seen in between 95% and 100% of patients depending on aetiology. Sensitivity and specificity of lipase in the diagnosis of acute pancreatitis was 96.6% and 99.4%, respectively. In contrast, the sensitivity and specificity of amylase in diagnosing acute pancreatitis were 78.6% and 99.1%, respectively. Single lipase assay in all patients presenting with abdominal pain to the surgical admission unit would result in a potential saving of £893.70/year., Conclusions: Determining serum lipase level alone is sufficient to diagnose acute pancreatitis and substantial savings can be made if measured alone.

Objectives: This study aimed to assess outcomes in patients who underwent hepatic resection for colorectal liver metastases (CRLM) with subcentimetre indeterminate pulmonary nodules (IPN) and to devise a management pathway for these patients., Methods: Patients undergoing CRLM resection from January 2006 to December 2010 were included. Survival differences following liver resection in patients with and without IPN were determined., Results: A total of 184 patients were included, 30 of whom had IPN. There were no significant differences between the IPN and non-IPN groups in terms of demographics, surgery and pathological factors. There were no significant differences between patients with and without IPN with respect to disease-free (P= 0.190) and overall (P= 0.710) survival. Fifteen patients with IPN progressed to metastatic lung disease over a median period of 10 months (range: 3-18 months); six of these patients underwent lung resection. Of the remaining 15 patients with IPN, eight showed no IPN progression and subsequent CT scans did not identify IPN in the remaining seven., Conclusions: Colorectal liver metastases patients with IPN who have resectable disease should be treated with liver resection and should be subject to intensive surveillance post-resection. Although 50% of these patients will progress to develop lung metastases, this does not appear to influence survival following liver resection., (© 2012 International Hepato-Pancreato-Biliary Association.)

Objective: There are few centres that offer all forms of small-bowel endoscopic modalities [capsule endoscopy (CE), push enteroscopy (PE), double-balloon enteroscopy (DBE) or single-balloon enteroscopy and intraoperative enteroscopy (IOE)]. Previous investigators have suggested that DBE may be more cost-effective as the first-line investigation. We evaluated the relationship among four modalities of small-bowel endoscopy in terms of demand, diagnostic yield, patient management and tolerability., Methods: Data were collected on patients who underwent PE and IOE since January 2002, CE since June 2002 and DBE since July 2006. These included age, sex, indication of referral, comorbidity, previous investigations and diagnosis obtained, including subsequent management change., Results: Demand for CE and DBE increased every year. A total of 1431 CEs, 247 PEs, 102 DBEs and 17 IOEs were performed over 93 months. The diagnostic yield was 88% for IOE compared with 34.6% for CE, 34.5% for PE and 43% for DBE (P<0.001). Management was altered by CE in 25%, by PE in 19% and by DBE in 33% of patients. However, 44% of patients who underwent DBE found the procedure difficult to tolerate. In 2009, for every 17 CEs performed, one patient underwent DBE locally., Conclusion: This is the first series to report the clinical experience of four modalities of small-bowel endoscopy from a single centre. The use of CE as first-line investigation, followed by PE/DBE or IOE, is potentially both less invasive and tolerable.

An integrated microdevice for measuring proton-dependent membrane activity at the surface of Xenopus laevis oocytes is presented. By establishing a stable contact between the oocyte vitelline membrane and an ion-sensitive field-effect (ISFET) sensor inside a microperfusion channel, changes in surface pH that are hypothesized to result from facilitated proton lateral diffusion along the membrane were detected. The solute diffusion barrier created between the sensor and the active membrane area allowed detection of surface proton concentration free from interference of solutes in bulk solution. The proposed sensor mechanism was verified by heterologously expressing membrane transport proteins and recording changes in surface pH during application of the specific substrates. Experiments conducted on two families of phosphate-sodium cotransporters (SLC20 & SLC34) demonstrated that it is possible to detect phosphate transport for both electrogenic and electroneutral isoforms and distinguish between transport of different phosphate species. Furthermore, the transport activity of the proton/amino acid cotransporter PAT1 assayed using conventional whole cell electrophysiology correlated well with changes in surface pH, confirming the ability of the system to detect activity proportional to expression level.

Objectives: Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability., Methods: Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords 'colorectal cancer', 'metastases', 'liver resection' and 'hepatectomy'., Results: Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81-1568 patients) and median follow-up was 35 months (range 16-52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis., Conclusions: There is no 'ideal' prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.

Background: The British Society of Gastroenterology guidelines for the management of malignant obstructive jaundice state: "If a stent is placed prior to surgery, this should be of the plastic type and it should be placed endoscopically. Self-expanding metal stents should not be inserted in patients who are likely to proceed to resection." In 2003, a small series of complications after endoscopic intervention caused a change in the authors' practice. Currently, all patients requiring relief of biliary obstruction before surgical resection undergo attempted insertion of a short metal biliary stent., Methods: Retrospective analysis of the authors' prospective database containing all patients presenting with periampullary and pancreatic tumors between January 2004 and May 2008 was performed., Results: The authors have attempted percutaneous placement of internal metal stents in 67 patients with resectable malignancies and biliary obstruction. Stenting was successful for 53 patients (79%), and 5 patients (9.4%) experienced complications. These five patients were successfully managed conservatively, and all proceeded to trial dissection. The mean bilirubin level was 253 mg/dl before intervention and 33 mg/dl before surgery for the stented patients compared with 308 mg/dl before intervention and 102 mg/dl before surgery for those who needed external drainage., Conclusions: Percutaneous insertion of short metal stents provides a safe and effective alternative to endoscopic stent placement for treating jaundice preoperatively in patients with potentially resectable tumors around the pancreatic head.

Background: Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas., Methods: An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed., Results: Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased., Conclusions: Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.

Objective: The aim of this study was to examine the relationship between tissue factor (TF), vascular endothelial growth factor (VEGF) and the onset of angiogenesis in the adenoma-carcinoma sequence (ACS), the stepwise process encompassing colorectal cancer (CRC) disease progression., Patients and Methods: 210 surgical specimens comprising the ACS were immunohistochemically stained for endothelial cells (CD31), VEGF and TF. Angiogenesis quantified using Chalkley grid analysis (microvascular density; MVD), and VEGF/TF expression were semiquantitatively graded and correlated with standard prognostic indicators including 5 year follow-up. VEGF and TF were measured by ELISA in tumour specimens and normal mucosa from an additional 90 CRC patients., Results: There was a significant increase in MVD across the ACS (p < 0.0005) with significant correlations with Dukes' stage (p = 0.01) and lymph node involvement (p = 0.02). The greatest increase in MVD was related to the onset of dysplasia, with an associated significant increase in VEGF expression (p < 0.0005). There was a significant relationship between VEGF and TF expression in the initial phase of the ACS (k = 0.44, p < 0.005), although no correlation between VEGF or TF, and MVD, tumour size, Dukes' classification, lymph node involvement or survival was found., Conclusions: These findings are the first to suggest that the angiogenic switch occurs at the onset of dysplasia in the ACS, and provide further evidence of the close association between VEGF and TF in the early stages of CRC development.

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.

Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice in the management of acute cholecystitis in the UK. A postal questionnaire was sent to 440 consultant general surgeons to ascertain their current management of patients with acute cholecystitis. Replies were received from 308 consultants who were involved in treating patients with acute cholecystitis of whom 18 transferred these patients on to another team for further management the day after admission. Thirty two consultants (11%) routinely treated patients by early cholecystectomy, with limiting factors stated to be the availability of surgical staff, theatre space, and radiological investigations. The remaining consultants (n = 258) routinely manage their patients conservatively with intravenous antibiotics and allow the inflammation to resolve before undertaking cholecystectomy at a later date. Indications for undertaking early cholecystectomy during the first admission by this latter group included the presence of spreading peritonitis due to bile leak, empyema, and unexpected space on theatre list. The commonest method for both elective and early cholecystectomy is laparoscopic, but the percentage of consultants using an open method rises from 8% in the elective situation to 47% for urgent early cholecystectomy. Despite evidence which strongly advocates early cholecystectomy, this practice is routinely carried out by only 11% of consultants in the UK at present.

Aims: A recent survey of UK general surgeons showed that almost 90% prefer to manage patients with acute cholecystitis by initial conservative management and delayed cholecystectomy (DC). The aim of this study was to assess the effectiveness of this management policy in a large university hospital., Patients and Methods: All patients admitted with acute cholecystitis between January 1997 and June 1999 who went on to have a cholecystectomy were identified. Patients were required to have right upper quadrant pain for > 12 h, a raised white cell count and findings consistent with acute cholecystitis on ultrasound to be included in the study., Results: 109 patients were admitted with acute cholecystitis (76 female, 33 male) with a median age of 62 years (range, 22-88 years). Conservative management failed in 16 patients (14.7%) who underwent emergency cholecystectomy due to continuing symptoms (9), empyema (4) and peritonitis (3). Symptoms settled in 93 patients and delayed cholecystectomy was performed without further problems in 66 (60.6%). 27 patients were re-admitted with further symptoms before their elective surgery and, of these, 3 were admitted for a third time before surgical intervention. Ten of the 30 re-admission episodes (33%) occurred within 3 weeks of discharge but 15 (56%) occurred more than 2 months after discharge. Elective surgery was undertaken at a median of 10 weeks post-discharge with 67% of operations occurring within 3 months. Mean total hospital stay (days) +/- SEM, for the three groups were: emergency surgery group, 10.21 +/- 0.85; uncomplicated DC group, 12.48 +/- 0.37; re-admitted group, 14.75 +/- 0.71., Conclusions: The policy of conservative management and DC was successful in 60.6% of cases but 14.7% of patients required emergency surgery and 24.8% were re-admitted prior to elective surgery with a resultant increase in total hospital stay. Performing elective surgery within 2 months of discharge in all cases would have reduced the re-admission rate by 56% and this along with the increased use of early cholecystectomy during the first admission are areas where the treatment of acute cholecystitis could be significantly improved.

Patients undergoing surgery for carcinoma of the breast are thought to be at lower risk of developing thromboembolic complications than those with abdominal malignancies and the role of the thromboprophylaxis is unproven. To determine current thromboprophylaxis practice a questionnaire was sent to 184 consultant surgeons thought to be involved in breast cancer surgery, of whom 137 responded (74%). Eleven surgeons no longer dealt with breast cancer patients. Of the remaining 126, thromboprophylaxis was given routinely by 88 (69.8%), with the commonest regimens being subcutaneous heparin only (n=43) and heparin combined with compression stockings (n=20). Patients with breast cancer were regarded as being at high risk of thromboembolic complications by 65 clinicians in this group (73.7%). Thirty-eight consultants did not use thromboprophylaxis routinely, the most commonly stated reasons were low/no risk of DVT (n=24), because of early postoperative mobilization (n=20) and increased risk of bleeding complications (n=15). Twenty clinicians reported a total of 22 deep venous thromboses and two pulmonary emboli affecting patients under their care who had surgery for breast cancer during the preceding year. Almost 70% of surgeons routinely employ thromboprophylaxis in patients undergoing breast cancer surgery but practice varies widely.

The main aim of this study was to establish the primary sub-specialist interest of a group of senior general surgical trainees and compare these results with the required sub-specialist interests in consultant vacancies advertised in the British Medical Journal between 3.1.98 and 25.12.99. Colorectal surgery was the most popular sub-specialty amongst trainees (29.4%) followed by upper gastrointestinal/hepato-pancreato-biliary (UGI/HPB) (27.2%) and vascular surgery (24.3%). The least popular sub-specialties were breast/endocrine (11.4%) and transplant (2.9%). A total of 324 consultant jobs were advertised, with the sub-specialist interest required as follows: Colorectal (25.6%), breast/endocrine (23.5%), vascular (20.4%), UGI/HPB (12%) and transplant (5.6%). Although this study only covers a two-year period, there are obvious discrepancies between trainees' sub-specialist interests and consultant vacancies. Whilst the jobs to trainees ratios are well matched in colorectal and vascular surgery, it appears that there are not enough transplant or breast trainees and too many UGI/HPB trainees for the number of jobs available. This problem needs urgent attention to avoid service shortfalls in unpopular sub-specialties and to avoid training people for jobs that do not exist.

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.

AIMS: Few published studies have detailed the long-term results of antireflux surgery. The aim of this study was to assess the long-term success of open Lind fundoplication in controlling the symptoms of gastro-oesophageal reflux disease. METHODS: One hundred and thirty-two patients with reflux symptoms underwent a primary Lind fundoplication between April 1986 and February 1994; all operations were supervised or performed by one surgeon. The median age at operation was 47 (range 17-77) years. All patients attended for follow-up in the early postoperative period. It was possible to conduct a telephone interview to assess long-term symptom control, at a median time of 9.5 (range 5-13) years following operation, in 112 of the 124 patients who were still alive. RESULTS: Ninety-one patients underwent oesophageal pH studies before and soon after operation. The oesophageal pH was less than 4 for a mean 14.9 per cent of the time before operation, falling to 2.4 per cent in the early postoperative period (P < 0.001, Wilcoxon test). At early postoperative assessment, two patients complained of mild reflux symptoms and 44 (33 per cent) complained of postfundoplication symptoms (dysphagia, epigastric bloating and early satiety). At telephone interview, 106 patients (95 per cent) were symptom free with regard to heartburn and regurgitation. Six patients have developed recurrent reflux symptoms, in four of whom symptoms are controlled by a proton pump inhibitor. Two patients have required further antireflux surgery, one within 2 months of the first procedure for severe dysphagia and the other for recurrent reflux. Significant postfundoplication symptoms persist (dysphagia with or without gas bloat) in three patients (3 per cent). CONCLUSIONS: Open Lind fundoplication appears to be effective in the long-term control of gastro-oesophageal reflux in 95 per cent of patients and represents a standard against which the long-term results of laparoscopic surgery will need to be compared.

AIMS: Several recent papers have advocated emergency cholecystectomy for patients with acute cholecystitis, stating that it is safe, cost effective and leads to less time off work. This study was designed to assess current practice in the management of acute cholecystitis in the UK. METHODS: A postal questionnaire was sent to 357 consultant surgeons who were thought to be involved in a general surgical on-call rota, to ascertain their current management of patients with acute cholecystitis. Replies were received from 250 consultants (70 per cent) of whom 242 (68 per cent) were involved in a general surgical take. Sixteen of these consultants, however, handed their patients with acute cholecystitis on to a different team the following day for further management. RESULTS: Twenty-seven consultants (12 per cent) routinely treat their patients by emergency cholecystectomy whenever possible, with 24 stating that they would do this within 72 h. Limiting factors to this practice were stated to be availability of surgical staff (15), theatre space (nine) and radiological investigations (four). The remaining consultants (n = 199) routinely manage their patients conservatively initially and providing they settle, either (1) book directly for cholecystectomy (n = 94, 47 per cent), (2) reassess as an outpatient (n = 65, 33 per cent), (3) either of above (n = 21; 11 per cent) or (4) refer on to a colleague (n = 19, 10 per cent). The commonest indications for acute cholecystectomy stated by consultants whose initial treatment policy is conservative are spreading peritonitis due to bile leak (93 per cent), empyema (89 per cent), unexpected space on a theatre list (28 per cent) and failure of an acute episode to settle (21 per cent). The laparoscopic method is the commonest for both elective and emergency cholecystectomy, but the percentage of consultants using an open method rises dramatically from 9 per cent in the elective situation to 48 per cent for emergency cholecystectomy. CONCLUSIONS: Despite evidence to support the increased use of emergency cholecystectomy, this practice is routinely carried out by only 12 per cent of consultants. However, of the consultants who treat their patients conservatively, 28 per cent are prepared to undertake emergency cholecystectomy if an unexpected space appears on the theatre list.

AIMS: The aim of this study was first to assess the primary subspecialist interests of general surgical specialist registrars who were accredited and still looking for a consultant position, or who were within 3 years of their CCST (certificate of completion of surgical training). These interests were then compared with subspecialist interests declared in consultant vacancies advertised in the British Medical Journal over the preceding 16 months. METHODS: All trainees in general surgery holding a national training number in six regions (Mersey, North West, Trent, Yorkshire, Northern, West Midlands) were identified, and those accredited or within 3 years of their CCST (n = 136) were telephoned to ascertain their primary subspecialist interest, whether they had a higher degree and what their desired consultant job would be. The consultant vacancies advertised in the British Medical Journal between 3 January 1998 and 8 May 1999 were assessed according to the required subspecialist interest. RESULTS: Upper gastrointestinal surgery is the second most popular subspecialty (n = 37; 27 per cent of trainees) after colorectal surgery (n = 40; 29 per cent of trainees). However, there were fewer consultant vacancies in upper gastrointestinal surgery (31 of 226; 14 per cent of jobs) than in any of the other three main subspecialist areas of general surgery (colorectal, vascular and breast/endocrine). The ratio of percentage of jobs to percentage of trainees was lowest in upper gastrointestinal surgery (0.50), compared with colorectal (0.77), vascular (0.89) and breast/endocrine (2.23) surgery. CONCLUSIONS: Upper gastrointestinal surgery appears to be the most competitive of the general surgical subspecialties at present, having by far the lowest ratio of jobs to trainees. In addition, 87 per cent of upper gastrointestinal trainees have or are completing a higher degree, and 43 per cent expressed a desire to work in a teaching hospital.

Objectives: To investigate the in vivo haemodynamic performance and neurological outcome of two types of carotid shunt., Design: Randomised single surgeon study of consecutive symptomatic patients., Setting: 163 consecutive patients undergoing carotid endarterectomy for symptomatic carotid disease were randomised to the Javid or Pruitt shunt., Chief Outcome Measures: Middle cerebral artery velocity (MCAV), preoperatively, during clamping, during shunting and post-restoration of flow, embolic episodes, neurological outcome., Main Results: The MCAV preoperatively, at carotid clamping, and postoperatively was the same for both groups (p > 0.15). During shunting the MCAV was significantly lower in the Pruitt group, p < 0.005, 59% of the Javid and 34% of the Pruitt shunts maintained MCAV at preoperative levels p < 0.005, chi 2 = 8.92. The Javid shunt produced significantly more emboli (73% of cases) at declamping than the Pruitt (41%), p < 0.0002, chi 2 = 14.7. Four Javid patients and one Pruitt had disabling thromboembolic strokes; overall thromboembolic stroke rate 3.7%. The difference in stroke rates was not statistically significant (p = 0.14)., Conclusions: The Pruitt shunt was unable to maintain preoperative MCAV in 66% of cases, the Javid shunt had a higher incidence of emboli on declamping. These factors may lead to an increased risk of stroke; however, the numbers required for statistical confirmation would be large.

Ulnar variance was determined on 1,023 radiographs of normal wrists taken in standardized fashion. There were 468 women and 555 men. The age range was 13 to 109 years. In both sexes, ulnar negative variance decreased significantly with increasing age. Possible reasons for this are discussed.

The study was undertaken to identify the presenting features of intestinal endometriosis and to evaluate its investigation and surgical management. Twenty-six cases of intestinal endometriosis were identified during a fourteen year period. The commonest site of occurrence was the rectosigmoid region (11 cases) followed by the appendix (9 cases), and ileocaecal region (6 cases). Abdominal pain was the main presenting feature in 20 cases, with associated nausea and vomiting in 12 cases and altered bowel habit in ten. Other presenting features included rectal bleeding, abdominal bloating and tenesmus. Endometriosis was not suspected preoperatively in any of the patients without a past history of this condition. Accurate preoperative diagnosis proved very difficult, with only laparoscopy providing definite evidence of intestinal endometriosis prior to formal surgery. Colonic resections were performed in 12 cases, small bowel resection in six cases and appendicectomy in nine cases, together with resection of adjacent adherent structures. This series illustrates the difficulty of establishing an accurate preoperative diagnosis, and the propensity of intestinal endometriosis to mimic other gastrointestinal diseases, particularly carcinoma and inflammatory bowel disease.