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To evaluate the effect of advanced age on peri-operative complications, recovery of liver function and overall survival in patients undergoing hepatectomy for colorectal liver metastases. Consecutive patients with colorectal liver metastases, who underwent potentially curative hepatectomy in two institutions in the UK from 2005 to 2012, were enrolled in this retrospective study. For each patient the institutional electronic records were interrogated and data were collected. A total of 260 patients were enrolled, 150/260 (57.7%) of whom were older than 60 years of age. 113 complications were recorded occurring in 97/260 of patients (37.3%). Univariate analysis of factors influencing the peri-operative morbidity showed that there was a significant association with an age greater than 60 years. This association remained significant in multivariate analysis (HR 1.92; 95% CI, 1.10-3.36; P=0.02). The number of technical surgical complications was comparable between the young and older group of patients (p=0.449). However, complications, which were not surgical such as pulmonary and cardiovascular, were higher in the older age group (p=0.031). Indices of pre-operative liver function (bilirubin, albumin, ALT) were comparable between the two age groups (p>0.5) and there was no difference in functional recovery of the liver. Although age greater than 60 years was not associated with reduced DFS, it was associated with decreased OS both in univariate and multivariate analysis (HR 2.45; 95% CI, 1.41-4.25;P=0.001). An age greater than 60 years is an independent prognostic factor of an increased postoperative nonsurgical complication rate and of decreased overall survival in patients undergoing partial hepatectomy for colorectal liver metastases. In this age group of patients significant post-operative complications relate not to the technical complexities or scale of procedure, but to the baseline physiological performance characteristics of the patient.

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.

Background Liver resection is currently the most efficient curative approach for a wide variety of liver tumors. The application of modern techniques and new surgical devices has improved operative outcomes. Radiofrequency ablation is used more often for liver parenchymal transection. This study aimed to assess the efficacy and safety of radiofrequency ablation-assisted liver resection. Methods A retrospective study of 145 consecutive patients who underwent radiofrequency ablation-assisted liver resection was performed. Intraoperative blood loss, need for transfusion or intraoperative Pringle maneuver, the duration of liver parenchymal transection, perioperative complications, and postoperative morbidity and mortality were all evaluated. Results Fifty minor and ninety-five major liver resections were performed. The mean intraoperative blood loss was 251 mL, with a transfusion rate of 11.7%. The Pringle maneuver was necessary in 12 patients (8.3%). The mean duration for parenchymal transection was 51.75 minutes. There were 47 patients (32.4%) with postoperative complications. There is no mortality within 30 days after surgery. Conclusions Radiofrequency ablation-assisted liver resection permits both major and minor liver resections with minimal blood loss and without occlusion of hepatic inflow. Furthermore it decreases the need for blood transfusion and reduces morbidity and mortality.

Neoadjuvant imatinib for gastrointestinal stromal tumours (GISTs) is increasingly used nowadays. As oesophagectomy is associated with high morbidity and mortality, a preoperative downsizing of an oesophageal GIST to limit the extent of resection would be ideal. Because these tumours are rare and neoadjuvant treatment with imatinib is recent, there is limited literature available regarding neoadjuvant administration of imatinib in patients with oesophageal GISTs. A 50-year-old woman presented with total dysphagia. An upper endoscopy and biopsy revealed a large submucosal KIT-positive GIST obstructing the mid oesophagus. CT confirmed a lesion measuring 99 mm × 50 mm × 104 mm. Because the size and location of the tumour increased the risk of intraoperative rupture, it was decided to administer preoperative imatinib. The patient had an excellent clinical and radiological response. Her dysphagia gradually resolved and the follow-up CT scans of the first 10 months showed a gradually reducing tumour size to 54 mm × 33 mm × 42 mm. The patient underwent an uneventful laparoscopic-assisted Ivor-Lewis oesophagectomy. Postoperatively, the patient continued with adjuvant imatinib. At the last follow-up, 1 year from operation and 38 months from the diagnosis, the patient is disease free.

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.

Totally implantable venous access ports are widely used for the administration of chemotherapy in patients with cancer. Although there are several approaches to implantation, here we describe Port-A-Cath(®) (PAC) placement by percutaneous puncture of the subclavian vein with ultrasonographic guidance.Data on our vascular access service were collected prospectively from June 2004. This service included port-a-caths and Hickman lines. Once 1000 consecutive port-a-caths(®) had been reached the study was closed and data analysed for the port-a-caths(®) alone. The left subclavian vein was the preferred site for venous access, with the right subclavian and jugular veins being the alternative choices if the initial approach failed. Patients were followed up in the short-term, and all the procedures were carried out by a single surgeon at each one of two institutions.Venous access by PAC was established in 100 % of the 1,000 cases. Of the 952 patients where the left subclavian vein was chosen for the first attempt of puncture, the success rate of PAC placement was 95 % (n = 904). Pneumothorax occurred in 12 patients (1.2 %), and a wound haematoma occurred in 4 (0.4 %) out of the total 1,000 patients. No infections were recorded during the immediate post-operative period but only in the long-term post-operative use with 8 patients requiring removal of the PAC due to infection following administration of chemotherapy.This is a very large series of PAC placement with an ultrasound-guided approach for left subclavian vein and X-ray confirmation, performed by a single surgeon, demonstrating both the safety and effectiveness of the procedure.

Duodenal metastasis from renal cell carcinoma is rare, and even rarer is a massive gastrointestinal bleeding from such tumours. Coeliac occlusive disease, although rarely symptomatic, can lead to ischaemic changes with anastomotic dehiscence and leaks when a patient undergoes pancreatoduodenectomy. A 41-year-old man with known metastasis to the adrenal glands and the second part of the duodenum close to the ampulla of Vater from clear cell renal cell carcinoma was admitted to our department due to massive gastrointestinal bleeding from the duodenal metastasis. Endoscopic control of the bleed was not possible, while the bleeding vessel embolization was able to control the haemorrhage only temporarily. An angiography during the embolization demonstrated the presence of stenosis of the coeliac artery and also hypertrophic inferior pancreaticoduodenal arteries supplying the proper hepatic artery via the gastroduodenal artery (GDA). The patient underwent emergency pancreatoduodenectomy with preservation of the gastroduodenal artery. The patient had an uneventful recovery and did not experience further bleeding. Also the blood flow to the liver was compromised as shown by the normal liver function tests (LFTs) postoperatively. To the best of our knowledge, this is the first report of a preservation of the GDA during an emergency pancreatoduodenectomy.

Although surgical and angiointervention techniques remain the cornerstone for the management of severe bleeding after trauma, adjunct therapeutic strategies such as local or systemic hemostatic agents can play an important role. This article reviews the role and efficacy of the available hemostatic agents.

Background Renal cell carcinoma accounts for 90 % of renal neoplasms and metastatic disease is common. One third of newly diagnosed cases will have synchronous metastases at diagnosis and further 25–50 % will develop metachronous disease. Case Presentation This study presents two new cases of gallbladder metastasis from renal cell carcinoma (RCC) from our institution and reviews the published literature. The final cohort included 52 evaluable patients. M/F ratio was 2:1 and median age was 62.5 years. Most patients were diagnosed incidentally after follow-up or staging imaging for RCC. Of the patients with available histology, all except one were clear cell type (n = 39) and 92 % were polypoid. Thirty-six patients demonstrated metachronous gallbladder metastasis with median disease-free interval (DFI) from nephrectomy of 4 years. The most frequent site of metastasis was the contralateral kidney (46.7 %) followed by the pancreas and lung. The median disease-free interval (DFS) after cholecystectomy was 37 months. Three- and five-year OS rates were 74 and 62 %, respectively. Age younger than 45 years (p = 0.008) and DFI

In this case report we detail the treatment of a patient with pancreatic ductal adenocarcinoma and a solitary liver metastasis who received nine cycles of FOLFIRINOX therapy with favourable response. The patient subsequently underwent synchronous distal pancreatectomy and hepatectomy with an R0 resection followed by three further cycles of FOLFIRINOX. At the last follow-up, 2 years from operation and 28 months from the diagnosis of metastatic pancreatic adenocarcinoma the patient remains disease free.

Background Despite recent advances in multimodality and multidisciplinary treatment of colorectal liver metastases, many patients suffer from extensive bilobar disease, which prevents the performance of a single procedure due to an insufficient future liver remnant (FLR). We present a novel indication for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a “liver-first” approach when inadequate FLR was faced preoperatively, in a patient with extensive bilobar liver metastatic disease of colon cancer origin. Case presentation A 51-year-old lady was referred to our center due to a stage IV colon cancer with extensive bilobar liver disease and synchronous colon obstruction. During the multidisciplinary tumor board, it was recommended to proceed first in a palliative loop colostomy (at the level of transverse colon) operation and afterwards to offer her palliative chemotherapy. After seven cycles of chemotherapy, the patient was re-evaluated by CT scans that revealed an excellent response (>30 %), but the metastatic liver disease was still considered inoperable. Moreover, with the completion of 12 cycles, the indicated restaging process showed further response. Subsequent to a thorough review by the multidisciplinary team, it was decided to proceed to the ALPPS procedure as a feasible means to perform extensive or bilobar liver resections, combined with a decreased risk of tumor progression in the interim. Conclusions All in all, ALPPS can offer a feasible but surgically demanding liver-first approach with satisfactory short-term results in selected patients. Larger studies are mandatory to evaluate short- and long-term results of the procedure on survival, morbidity, and mortality.

The discovery of prognostic factors for patients who undergo hepatectomy for colorectal liver metastases (CRLM) in the era of neoadjuvant chemotherapy is imperative. This study aimed to establish a simple, cheap and easily available prognostic score for these patients.Preoperative carcinoembryonic antigen (CEA), serum alkaline phosphatase (ALP), and lymphocyte count (LC) were used for the establishment of a prognostic score (CALy PS). The cut-off levels of these variables were determined by applying receiver operating curve (ROC) analysis. The final prognostic score assigned one risk point for each variable (CEA4 μg/L, ALP93 U/L, and LC≥1.6x10(9)/L).One hundred and thirty-five patients were included. Two risk categories were established with 0-1 and 2-3 points, respectively. CALy 0-1 vs CALy 2-3, and CALy 2-3 were associated with decreased disease free survival (DFS) and overall survival (OS) both in univariate and multivariate analysis (DFS: HR 1.84; 95% CI 1.18-2.86; p=0.007; OS: HR 2.25; 95% CI 1.23-4.11; p=0.008). When four risk categories were established with 0,1,2,and 3 points,CALy was again associated with decreased DFS and OS both in univariate and in multivariate analysis (DFS: HR 1.37; 95% CI 1.083-1.74; p=0.009; OS:HR 1.84; 95% CI 1.31-2.59; p0.001). Three-year DFS rates for these categories (CALy 0, CALy 1, CALy 2, and CALy 3) were 45, 38, 15 and 7%, respectively, and the 5-year OS rates were 78, 68, 32, and 24%, respectively.This simple, cheap, and easily available risk score provides good prognostic accuracy for both DFS and OS for patients undergoing liver resection for liver-only colorectal metastases after neoadjuvant chemotherapy.

Bevacizumab is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF), often used in combinational chemotherapy regimens for the treatment of patients with colorectal liver metastases. However adverse events have been attributed to the use of bevacizumab including gastrointestinal perforations, thrombotic events, hypertension, bleeding, and wound healing complications. 53-year-old male, with a history of colorectal cancer with liver metastasis, receiving a combination of cytotoxic chemotherapy (FOLFIRI, irinotecan with fluorouracil and folinic acid) with bevacizumab presented as an emergency with an incarcerated incisional hernia. The last administration of chemotherapy and bevacizumab had taken place 2 weeks prior to this presentation. As the risk of strangulation of the bowel was increased, a decision was made to take the patient to theatre, although the hazard with respect to wound healing, haemorrhage, and infection risk was high due to the recent administration of chemotherapy with bevacizumab. The patient underwent an open repair of the incarcerated recurrent incisional hernia with placement of a biological mesh, and the postoperative recovery was uncomplicated with no wound healing or bleeding problems.

Backgrounds/aims It is important to point out that the identification of inflammation is an essential component of the pathogenesis and the progression of cancer. In this study, we analysed the neutrophil-to-lymphocyte ratio (NLR) and the platelets-to-lymphocyte ratio (PLR), with an overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC), who were treated with a resection following or not following a procedure of neoadjuvant chemotherapy/chemoradiation. We intended to identify the significance of the role of NLR and PLR, as prognostic markers in patients undergoing surgery for PDAC. Methods There were 127 patients enrolled in the study. The NLR and PLR were calculated on the basis of the pre-treatment blood cell count. An NLR>4 and a PLR >120 were considered to be elevated as measured. OS was analysed in relation to the NLR and PLR values, by using both the Kaplan-Meier and multivariate Cox-regression methods. Results Both high the NLR and high PLR were associated with a decreased OS in the univariate analysis. In the multivariate analysis, the high NLR, but not the high PLR, was an independent predictor of a decreased OS. When we divided patients into three groups (group 1: normal both NLR and PLR, group 2: high NLR or high PLR, group 3: high both NLR and PLR), the three-years OS rates for these groups were 48%, 32%, 7% (p=0.001) respectively. Conclusions It is noted that the pre-treatment NLR is an independent adverse prognostic factor, and considered to be superior to the PLR, in patients who undergo a resection for PDAC following or not neoadjuvant chemotherapy/chemoradiation.

This study was designed to investigate the prognostic impact of elevated platelet to lymphocyte ratio (PLR) on survival for oesophageal and junctional adenocarcinoma (OJA) treated with neoadjuvant chemotherapy in a curative intent. From 2004 to 2014, 153 consecutive patients with OJA were included. PLR was measured at first diagnosis. Receiver Operating Characteristic curve analysis was performed to determinate PLR threshold. Cox multivariate model was used to assess correlation between PLR and survival. Cut-off value for PLR was 192, which identified 2 groups of patients: low (n = 122) and high PLR value (n = 31). Both groups were comparable by patient (age, sex, ASA score) and tumour characteristics (differentiation, TNM stage, location). Five year overall survival (OS) was 65%. OS and DFS were reduced in the high PLR group: p = 0.019 and p = 0.016, respectively. PLR was associated with increased recurrence (54.8% vs. 35.2%, p = 0.046) and cancer-related death (41.9% vs. 23.8%, p = 0.043) rates. On multivariate analysis, elevated PLR was associated with decreased DFS (HR = 2.85, 95%CI = 1.54-5.26, p = 0.001) and OS (HR = 2.47, 95%CI = 1.21-5.01, p = 0.012). This study demonstrates that elevated PLR is associated with poor OS and DFS for OJA treated with a curative intent and has the potential to be a useful prognostic biomarker for treatment planning.

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury.Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient’s demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction.Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists.Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Pneumatosis intestinalis, defined as gas in the bowel wall, is often first identified on abdominal radiographs or computed tomography (CT) scans. It is a radiographic finding and not a diagnosis, as the etiology varies from benign conditions to fulminant gastrointestinal disease. We report here a case of pneumatosis intestinalis associated with cetuximab therapy for squamous cell carcinoma of head and neck. The patient underwent laparotomy based on the CT scan and the result was pneumatosis intestinalis without any signs of necrotizing enterocolitis.

Pneumatosis intestinalis, defined as gas in the bowel wall, is often first identified on abdominal radiographs or computed tomography (CT) scans. It is a radiographic finding and not a diagnosis, as the etiology varies from benign conditions to fulminant gastrointestinal disease. We report here a case of pneumatosis intestinalis associated with cetuximab therapy for squamous cell carcinoma of head and neck. The patient underwent laparotomy based on the CT scan and the result was pneumatosis intestinalis without any signs of necrotizing enterocolitis.

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.

Background: Hemorrhage is undoubtedly one of the main factors contributing to morbidity and mortality in liver resections. Vascular occlusion techniques are effective in controlling intraoperative bleeding, but they cause liver damage due to ischemia. We evaluated the effectiveness and safety of using a combined technique for hepatic parenchymal transection without liver inflow occlusion. Methods: Three hundred and thirteen consecutive patients who underwent liver resection in four hepato-pancreato-biliary units. Hepatic parenchymal transection was carried out using a combined technique of saline-linked radiofrequency precoagulation and ultrasonic aspiration without liver inflow occlusion. Results: During the study period 114 minor and 199 major hepatic resections were performed. The mean amount of intraoperative blood loss was 377 ml (SD 335 ml, range 50 to 2,400 ml) and the blood transfusion rate was 10.5%. The median amount of blood loss during parenchymal transection and parenchymal transection time was 222 ml (SD 224 ml, range 40 to 2,100 ml) and 61 minutes (range 12 to 150 minutes) respectively. There were two postoperative deaths (0.6%). Complications occurred in 84 patients (26.8%) and most complications were minor. Conclusions: Combined technique of saline-linked radiofrequency ablation and ultrasonic aspiration for liver resection is a safe method for both major and minor liver resections. The method is associated with decreased blood loss, reduced postoperative morbidity, and minimal mortality rates. We believe that this combined technique is comparable to other techniques and should be considered as an alternative.

In this case report we detail the treatment of a patient with pancreatic ductal adenocarcinoma and a solitary liver metastasis who received nine cycles of FOLFIRINOX therapy with favourable response. The patient subsequently underwent synchronous distal pancreatectomy and hepatectomy with an R0 resection followed by three further cycles of FOLFIRINOX. At the last follow-up, 2 years from operation and 28 months from the diagnosis of metastatic pancreatic adenocarcinoma the patient remains disease free.

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

We investigate the neutrophil to lymphocyte ratio (NLR) as a potential prognostic factor for patients undergoing curative liver resection for colorectal liver metastasis (CRLM).We 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.One 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).Elevated 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.

Hepatic resection is the mainstay of the curative treatment of primary hepatic tumors, with constantly improving short and long term results. Radiofrequency ablation (RFA)-assisted liver resection is a relatively new method of transection of the liver parenchyma with favorable intra- and perioperative results. The aim of this study was to investigate the oncological efficacy (long term overall survival/OS and disease free survival/DFS) and to confirm the favorable short term morbidity and mortality.Between May 2004 and January 2007, 28 patients underwent 32 resections with removal of 50 hepatocellular carcinoma (HCC) lesions. The technique of parenchymal transection has been described previously as RFA-assisted liver resection.Thirty-day morbidity and mortality were 42.8 and 0%, respectively. Blood transfusion was necessary for 28.5% of the patients. The median hospital stay was 16.5 days (range 5-34). The 1- and 3-year OS were 92.9 and 65.7%, respectively. The 1- and 3-year DFS were 62.3 and 54.6- respectively. No patient developed metastatic disease or local recurrence at the margin site. Twelve patients (42.9%) developed in-the-liver recurrence away from the resection area.RFA-assisted liver resection is a safe and oncologically efficacious method for the surgical treatment of HCC with results comparable to other surgical techniques.

Surgical resection is the only potentially curative strategy in the treatment of patients with colorectal liver metastases (CLM). Unfortunately, only about 10%–15% of patients are candidates for resection. Preoperative chemotherapy aims to increase the number of patients that may be eligible for liver resection by downsizing liver metastases. For patients with unresectable, chemotherapy refractory CLM the available treatment options are limited. Selective interarterial radiation therapy (SIRT) is one of the most promising treatment options for this group of patients. Although only a small number of these patients have been reported as becoming candidates for potentially curative hepatic resection following sufficient reduction in the volume of liver metastases, the question arises regarding the safety of liver resection in these patients. We report a case of a patient who presented unresectable liver relapse of CLM after previous right hepatectomy. He underwent SIRT which resulted in downsizing of the liver metastases making the patient candidate for left lateral sectionectomy. He underwent the redo hepatectomy without any complications. To the best of our knowledge, this is the first reported case of redo hepatectomy after SIRT for CLM.

Laparoscopic adjustable gastric banding is a common and effective minimally invasive procedure in the treatment of morbid obesity. Common complications of the procedure include productive burping, ulceration, gastritis, erosion, slippage, problems with the port, bleeding and infection. We report a case of acute appendicitis caused by gastric banding in a female patient. Gastric band encircled the appendix causing lumen obstruction and infection. The patient developed symptoms of topical acute peritonitis and an appendisectomy was performed.

Malignant hepatic epithelioid hemangioendothelioma (HEHE) is a rare malignant tumor of vascular origin. Nonspecific symptoms and the absence of experience of surgeons, radiologists, and histopathologists due to the rarity of HEHE make the diagnosis of this entity very challenging. Misdiagnosis is not a rare event, and the consequences of such an event are catastrophic. We report a case of a patient suffering from HEHE in which the initial diagnosis was hepatocellular carcinoma (HCC). The presence of normal laboratory values, liver function tests, tumor markers along with the absence of a chronic liver disease, or any other predisposing factors for HCC, was in contrast with the diagnosis of HCC. Clinical suspicion drove us to the repetition of a liver biopsy and the reevaluation of the sample by a more experience histopathology department in liver tumors. The last biopsy confirmed the diagnosis of HEHE, and the patient escaped any unnecessary treatment for a nonexisting HCC.

In the last thirty years, the widespread use of endoscopic retrograde cholangiopancreatography (ERCP) has radically changed the management of patients with diseases of the extrahepatic biliary tract and pancreas. Pneumothorax is a rare complication of ERCP. We report two cases of pneumothorax following elective ERCP for ductal stone clearance. The first patient was a 45-year-old female, who developed respiratory distress, abdominal pain, and profoundly abdominal distention immediately after the procedure. Imaging studies revealed the presence of a right-side pneumothorax, pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum. The second patient was a 94-year-old female, who developed tension pneumothorax with clinical signs of shock during the procedure. Imaging studies revealed the presence of a right-side pneumothorax without free air in the mediastinum and retroperitoneal space. The imaging findings suggest that the occurrence of this rare complication in our patients was caused by entirely different pathophysiological mechanisms. Both patients were successfully treated with chest tube insertion, and no further intervention was required. Clinicians should be aware of this serious complication because delayed diagnosis may involve significant morbidity and mortality risks.

Duplication cysts (DCs) of alimentary tract are rare congenital malformations. They are firmly attached to the wall of the gastrointestinal tract and they are supplied by surrounding mesenteric blood vessels. More than 80% of cases occur before the age of two years and only a minority of cases present in adulthood. “Completely isolated duplication” of the alimentary tract is an extremely rare variety of gastrointestinal duplications. They have gastrointestinal epithelial and wall characteristics without an anatomic association with the alimentary tract. Their main characteristic is that they have their own blood supply. A 20-year-old male was admitted to our department with symptoms persisting for a period of one week prior to admission, which included abdominal pain, fever, and a palpable abdominal mass. CT revealed an unexplained intraperitoneal abscess. This case represents a rare clinical example of infected isolated duplication cyst managed with percutaneous drainage and surgical excision of the cyst 3 weeks later. To the best of our knowledge, this is the first reported case to use this approach.

The small intestine is the third in frequency intraperitoneal organ which is injured after blunt trauma of the abdomen. In most of the cases, this type of injuries is accompanied by other injuries, which make it more difficult to diagnose. Failure of diagnosis and delay in treating these injuries significantly increase the morbidity and mortality of these patients. Abdominal visceral injuries after flipping the handlebar of the bike are common in children. Such injuries can cause injury to both solid and hollow abdominal viscera. Unlike children, adults’ abdominal visceral injuries after flipping the bike’s handlebar are extremely rare. A 25-year-old man was admitted to our department due to progressively abdominal pain after an accident with the handlebar of his bike. The subsequent CT scan after per os administration of contrast medium revealed the presence of free intraperitoneal contrast. It is a rare case of jejunal perforation after flipping the handlebar of the bicycle which was treated by partial removal of the injured part of jejunum and end-to-end anastomosis. To the best of our knowledge this is the first time we describe such an injury with this mechanism to an adult.