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Introduction: Neuroendocrine tumors (NETs) with liver metastases have a poor prognosis. Somatostatin analogues and chemotherapy are used with some success. Transarterial Embolization (TAE) is increasingly used to improve symptom control and reduce tumor size. Aim(s): To investigate outcome of patients treated with TAE in the last five years. Materials and methods: We identified all patients who received TAE within the last five years. We looked at case notes for: demographics, type of NET, treatment received and symptoms. We determined the number of TAE treatments per patient, symptoms, biochemical and radiological improvement. Mean survival time defined as from time TAE to date of death or most recent follow-up. Results: Twenty-two patients received TAE (13F/9F). Sixteen carcinoid - one bronchial, four small bowel, two large bowel, two pancreas, seven unknown primary, one of ovarian origin, two pancreatic, one stomach. All patients reported symptom improvement, mean no. of diarrhoea episodes fell from 6.1 (1-10) to 1.8 (0-5), mean no. flushing episodes fell 4.1 (1-10) to 0.6 (0-3). The percentage decrease in 5HIAA in the nine patients available mean % 5HL4A decrease 45% (21.6-85.5). RECIST criteria - 17 stable disease, four partial response and two progressive disease. One-year survival 100%, mean survival from diagnosis 49.3 months. Mean survival after TAE was 26.6 months (12-48). Conclusion: TAE improves symptoms, and there is objective evidence of improvement in radiology and biochemistry. Further studies needed to determine effect on survival. [ABSTRACT FROM AUTHOR]

A surface plasmon resonance imaging (SPRI)-based biosensor is demonstrated for the detection of both hydrogen peroxide (H 2 O 2 ) and glucose. The H 2 O 2 to be detected acts as an oxidant and etch the silver film. This process gradually effects on resonance condition and consequently the reflected light intensity at a fixed angle. The etching rate of the silver film shows a clear relation with the H 2 O 2 concentration. Therefore, monitoring the reflected light intensity progressively changing over a few minutes, enables accurate detection of H 2 O 2 concentrations ranging from 0 to 200 μM (within physiological range of 0.25-50 μM), with a remarkable limit of detection (LOD) as low as 40 nM. In this regard, the behavior of the surface plasmon resonance (SPR) dip in response to the reduction of the silver film thickness is predicted by Winspall simulation software. These simulation results are in good agreement with the experimental results. Moreover, the proposed method can be applied to determine glucose concentrations ranging from 0 to 10 mM, encompassing the physiological range of 3-8 mM. This is achieved by observing the generated H 2 O 2 through the enzymatic oxidation reaction between glucose and glucose oxidase (Gox). The sensor demonstrates remarkable sensitivity and selectivity, with a detection limit as low as 175 μM for glucose concentration. Furthermore, accurate measurement of glucose concentration in an actual human serum sample is achievable with the proposed sensor, using the standard addition method. The suggested glucose sensor shows promising prospects for use in routine glucose testing, employing a label-free, real-time, and multiplex detection approach.© 2017 Elsevier Inc. All rights reserved., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: In liver cirrhosis, acute variceal bleeding (AVB) is associated with a 1-year mortality rate of up to 40%. Data on early or pre-emptive transjugular intrahepatic portosystemic stent-shunt (TIPSS) in AVB is inconclusive and may not reflect current management strategies. Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in AVB (REACT-AVB) aims to investigate the clinical and cost-effectiveness of early TIPSS in patients with cirrhosis and AVB after initial bleeding control., Methods and Analysis: REACT-AVB is a multicentre, randomised controlled, open-label, superiority, two-arm, parallel-group trial with an internal pilot. The two interventions allocated randomly 1:1 are early TIPSS within 4 days of diagnostic endoscopy or secondary prophylaxis with endoscopic therapy in combination with non-selective beta blockers. Patients aged ≥18 years with cirrhosis and Child-Pugh Score 7-13 presenting with AVB with endoscopic haemostasis are eligible for inclusion. The primary outcome is transplant-free survival at 1 year post randomisation. Secondary endpoints include transplant-free survival at 6 weeks, rebleeding, serious adverse events, other complications of cirrhosis, Child-Pugh and Model For End-Stage Liver Disease (MELD) scores at 6 and 12 months, health-related quality of life, use of healthcare resources, cost-effectiveness and use of cross-over therapies. The sample size is 294 patients over a 4-year recruitment period, across 30 hospitals in the UK., Ethics and Dissemination: Research ethics committee of National Health Service has approved REACT-AVB (reference number: 23/WM/0085). The results will be submitted for publication in a peer-reviewed journal. A lay summary will also be emailed or posted to participants before publication., Trial Registration Number: ISRCTN85274829; protocol version 3.0, 1 July 2023., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background and Aims: Cirrhosis increases perioperative and postoperative mortality in nonhepatic surgery. Transjugular intrahepatic portosystemic shunt (TIPSS), by reducing portal pressure, may reduce intraoperative bleeding and postoperative decompensation. We report our experience of prophylactic TIPSS in nonhepatic surgery., Methods: Patients who underwent prophylactic TIPSS before nonhepatic surgery were identified from database with retrospective data collection via an e-patient record system. Primary outcome was discharged without hepatic decompensation after a planned surgery., Results: Twenty-one patients [age (median, range): 55, 33-76 years, Child's score: 6, 5-9] who underwent prophylactic TIPSS before nonhepatic surgery over a period of 9 years were included. All patients underwent successful TIPSS with a reduction in portal pressure gradient from 21.5 (11-35) to 16 (7-25) mmHg (P < 0.001). Immediate post-TIPSS complications were seen in 7 (33%) patients including hepatic encephalopathy in four. Eighteen patients (86%) underwent planned surgical intervention. Significant postoperative complications included hepatic encephalopathy (3), sepsis (2) and bleed (1). Two patients died postoperatively with multi-organ failure. The primary outcome was achieved in 12 (57%) patients. Post-TIPSS portal pressure gradient was significantly higher in patients with the adverse primary outcome. Over a follow-up period of 11 (1-78) months; 1-, 6- and 12-months' survival was 90, 80 and 76%, respectively., Conclusion: Prophylactic TIPSS is associated with complications in up to one-third of patients, with 57% achieving the primary outcome. Careful patient selection in a multidisciplinary team setting is essential. Multicentre studies are necessary before the universal recommendation of prophylactic TIPSS., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Prothrombin induced by vitamin K absence II (PIVKA-II) has recently been validated internationally as a diagnostic biomarker for hepatocellular carcinoma (HCC), as part of the GALAD model. However, its role as a treatment response biomarker has been less well explored. We, therefore, undertook a prospective study at a tertiary centre in the UK to evaluate the role of PIVKA-II as a treatment response biomarker in patients with early, intermediate and advanced stage HCC. In a cohort of 141 patients, we found that PIVKA-II levels tracked concordantly with treatment response in the majority of patients, across a range of different treatment modalities. We also found that rises in PIVKA-II levels almost always predated radiological progression. Among AFP non-secretors, PIVKA-II was found to be informative in 60% of cases. In a small cohort of patients undergoing liver transplantation, pre-transplant PIVKA-II levels predicted for microvascular invasion and poorer differentiation. Our results demonstrate the potential utility of PIVKA-II as a treatment response biomarker and in predicting microvascular invasion, in a Western population. PIVKA-II demonstrated improved performance over AFP but, as a single biomarker, its performance was still limited. Further larger prospective studies are recommended to evaluate PIVKA-II as a treatment response biomarker, within the GALAD model., Competing Interests: CONFLICTS OF INTEREST PP reports consultancy fees from Bayer, Eisai, MSD and Roche. SS reports consultancy fees from Faron Pharmaceuticals. YTM reports consultancy fees from Astra Zeneca, Bayer, Eisai, Faron Pharmaceuticals, Ipsen and Roche. All potential conflicts of interests were outside of the submitted work. All other authors declare no competing interests., (Copyright: © 2021 Sagar et al.)

Background: The aim of this study was to evaluate potential risk factors associated with benign lesions and perihilar cholangiocarcinoma (PHC) in patients presenting with proximal biliary strictures (PBS)., Methods: Patients with PBS who were referred to a specialist HPB centre between 2008 and 2016 were identified. Patients with primary sclerosing cholangitis, metastatic PHC or hilar obstruction by a peripheral tumour were excluded. The final diagnosis was determined either by (1) resection histology or (2) combination of biopsy and clinical course. Multivariable analysis of clinical, laboratory and radiological data was undertaken to identify independent predictors of benign and malignant lesions., Results: 155 consecutive patients were identified, including 25 patients (16%) with benign PBS. Abdominal pain (odds ratio [OR] 3.36; p = 0.027), serum CA19.9 < 100 U/ml (OR 10.35; p = 0.001), and absence of mass on imaging (OR 4.66; p = 0.004) were all associated with the presence of benign lesions on multivariable analysis., Conclusions: This study has identified several independent variables that may differentiate between benign and malignant proximal biliary strictures. A larger multi-institutional study would be warranted to validate these findings, and to develop a risk score to stratify patients with suspected PHC., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. All rights reserved.)

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS., Competing Interests: Competing interests: Dr David Patch: contribution to charity-administered educational fund for teaching purposes (Cook Medical). Dr Dhiraj Tripathi: educational funding (Gore Ltd). Chief investigator of CALIBRE trial investigating non-selective beta-blockers versus variceal band ligation in variceal bleeding (NIHR HTA funding). Member of National Institute of Health and Care Excellence (NICE) Interventional Procedures Advisory Committee (IPAC). Dr Homoyon Mehrzad: speaker fees (Gore Ltd) and educational funding (Gore Ltd). Professor Peter Hayes: speaker fees (Gore Medical). Dr Simon Travis: educational donations for sponsorship to attend scientific meetings and fund courses to train on specific equipment (Abbott Medical, Gore Ltd, Boston Scientific). Dr Richard Aspinall: trustee to charity Liver4Life. Other authors have not declared any conflicts of interest., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Photothermal effect in plasmonic nanostructures (thermoplasmonic), as a nanoscale heater, has been widely used in biomedical technology and optoelectronic devices. However, the big challenge in this effect is the quantitative characterization of the delivered heat to the surrounding environment. In this work, a plasmonic metasurface (as a nanoheater), and a Fabry-Perot (FP) cavity including liquid crystal (as a thermometer element) are integrated. The metasurface is manufactured through a bottom-up deposition method and has a near perfect absorption that causes an efficient temperature rising in the photothermal experiment under a low intensity of irradiation ($0.25\; {\rm W}/{{\rm cm}^2}$0.25W/cm 2 ). Generated heat from the metasurface dissipates to the liquid crystal (LC) layer and makes a spectral shift of FP modes. More than 50°C temperature elevation with accuracy of 1.3°C are measured based on the consistency of anisotropic thermo-tropic data of the LC and a spectral shift of FP modes. The calculated figure of merit (FoM) of the constructed device, which indicates the temperature sensitivity, is 22. The FoM is four times more than other reported thermometry devices with broad spectral width. The device can be also used as an all-optical device to control the plasmonic resonance spectrum.

Background: Budd-Chiari syndrome (BCS) is a rare but fatal disease caused by obstruction in the hepatic venous outflow tract., Aim: To provide an update of the pathophysiology, aetiology, diagnosis, management and follow-up of BCS., Methods: Analysis of recent literature by using Medline, PubMed and EMBASE databases., Results: Primary BCS is usually caused by thrombosis and is further classified into "classical BCS" type where obstruction occurs within the hepatic vein and "hepatic vena cava BCS" which involves thrombosis of the intra/suprahepatic portion of the inferior vena cava (IVC). BCS patients often have a combination of prothrombotic risk factors. Aetiology and presentation differ between Western and certain Asian countries. Myeloproliferative neoplasms are present in 35%-50% of European patients and are usually associated with the JAK2-V617F mutation. Clinical presentation is diverse and BCS should be excluded in any patient with acute or chronic liver disease. Non-invasive imaging (Doppler ultrasound, computed tomography, or magnetic resonance imaging) usually provides the diagnosis. Liver biopsy should be obtained if small vessel BCS is suspected. Stepwise management strategy includes anticoagulation, treatment of identified prothrombotic risk factors, percutaneous revascularisation and transjugular intrahepatic portosystemic stent shunt to re-establish hepatic venous drainage, and liver transplantation in unresponsive patients. This strategy provides a 5-year survival rate of nearly 90%. Long-term outcome is influenced by any underlying haematological condition and development of hepatocellular carcinoma., Conclusions: With the advent of newer treatment strategies and improved understanding of BCS, outcomes in this rare disease have improved over the last three decades. An underlying haematological disorder can be the major determinant of outcome., (© 2019 John Wiley & Sons Ltd.)

Active plasmonics combined with liquid crystal (LC) has found many applications in nanophotonics. In this Letter, we propose a fast response active plasmonic device based on the interplay of the plasmonic spectrum and Fabry-Perot (FP) modes. The plasmonic spectrum and FP modes are excited in a layer of gold nanoparticle (NP) islands and an LC microcavity, respectively. The FP mode splits the extinction spectrum of the NP to narrow bands, which are named hybrid modes (HMs). Due to multiple reflections of photons inside the cavity, the extinction coefficient is enhanced compared to a bare NP layer. An external electric field shifts the HM leading to a significant increase in the figure of merit (FoM) related to the activation ability by up to a factor of 45. Additionally, we could reduce the response time of active plasmonics. This decrease in response time is achieved through polymer-dispersed LC (PDLC) in the microcavity. Utilizing a mesogenic monomer in PDLC reduces the response time of the HM into the microsecond range, while the sample remains transparent.

Background: Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre-assessment of transjugular intrahepatic portosystemic stent-shunt., Aim: Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent-shunt insertion in cirrhosis., Methods: Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent-shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30-day and overall transplant free-survival were assessed., Results: One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child-Pugh B/C 71/14.5%; Model For End-Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent-shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty-day and overall transplant-free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385-2368) days follow-up. Model for End-Stage Liver Disease (P < 0.001) and Child-Pugh Score (P = 0.002) significantly predicted 30-day and overall transplant-free survival. Model for End-Stage Liver Disease ≥15 implied three-fold risk of death. Six per cent (n = 7) of patients pre-transjugular intrahepatic portosystemic stent-shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1-3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival post-transjugular intrahepatic portosystemic stent-shunt., Conclusions: Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent-shunt insertion. Model for End-Stage Liver Disease and Child-Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stent-shunt insertion., (© 2019 John Wiley & Sons Ltd.)

Budd-Chiari syndrome (BCS) is a rare but fatal disease caused by the obstruction in hepatic venous outflow tract (usually by thrombosis) and is further classified into two subtypes depending on the level of obstruction. Patients with BCS often have a combination of prothrombotic risk factors. Clinical presentation is diverse. Stepwise management strategy has been suggested with excellent 5-year survival rate. It includes anticoagulation, treatment of identified prothrombotic risk factor, percutaneous recanalization, and transjugular intrahepatic portosystemic shunt (TIPS) to reestablish hepatic venous outflow and liver transplantation in unresponsive patients. Owing to the rarity of BCS, there are no randomized controlled trials (RCTs) precisely identifying the timing for TIPS. TIPS should be considered in patients with refractory ascites, variceal bleed, and fulminant liver failure. Liver replacement is indicated in patients with progressive liver failure and in those in whom TIPS is not technically possible. The long-term outcome is usually influenced by the underlying hematologic condition and the development of hepatocellular carcinoma. This review focuses on the timing and the long-term efficacy of TIPS in patients with BCS., Competing Interests: Conflict of Interest Conflict of Interests: Dr. Dhiraj Tripathi and Dr. Homoyon Mehrzad got speaker fees for Gore Medical.

Aim: To analyse the risk of pregnancy (a prothrombotic state) in patients with Budd-Chiari Syndrome (BCS)., Methods: Retrospective study of pregnancy in women with known BCS at single center from January 2001 to December 2015., Results: Out of 53 females with BCS, 7 women had 16 pregnancies. Median age at diagnosis of BCS in these women was 25 years (range 21-34 years). At least one causal factor for BCS was identified in 6 women (86%). Six women had undergone radiological decompressive treatment. All patients had anticoagulation. Six fetuses were lost before 20 wk gestation in 2 women. There were 9 deliveries over 32 wk gestation and one delivery at 27 wk. All infants did well. Seven babies were born by emergency caesarean section. There were no cases of thrombosis. Two patients had notable vaginal (PV) bleeding in 3 pregnancies. None of the patients had variceal haemorrhage. Two patients were diagnosed with pulmonary hypertension, one during pregnancy and the other in the post-partum period. There was no maternal mortality., Conclusion: Maternal outcomes in patients with treated BCS are favourable and fetal outcomes beyond 20 wk gestation are good. There has been increased rate of caesarean section. Pulmonary hypertension is an important finding that needs further validation. These patients should be managed in centers experienced in treating high-risk pregnancies., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report.

Ascites is well-documented sequelae of liver cirrhosis with significant impact on survival in this group of patients. Among the many established management strategies for the same is the use of an implantable mechanical device, called alfapump ® (Sequana Medical, Zurich, Switzerland), that removes ascitic fluid by pumping it from the peritoneal cavity to the urinary bladder. Until recently, this device has been surgically placed under general anaesthesia. We describe successful interventional radiological implantation under conscious sedation in three patients with minimal complications. This device can serve as an alternative to transjugular intrahepatic portosystemic shunt for the management of refractory ascites; however, further studies are required to understand the device better.

Background: Endoscopic ultrasound fine needle aspiration (EUS-FNA) and percutaneous transhepatic cholangiographic endobiliary forceps biopsy (PTC-EFB) are valid procedures for histological assessment of proximal biliary strictures (PBS), but their performances have never been compared. This study aimed to compare the diagnostic performance of these two techniques., Method: The diagnostic performances of EUS-FNA and PTC-EFB were compared in a retrospective cohort of patients assessed for PBS from 2011 to 2015 at a single tertiary centre. An inverse probability of treatment weighting (IPTW) was performed to adjust for covariate imbalance., Results: A total of 102 EUS-FNAs and 75 PTC-EFBs (performed in 137 patients) were compared. Patients in the PTC-EFB group had higher preoperative bilirubin (243 versus 169 μmol/l, p = 0.005) and a higher incidence of malignancy (87% versus 67%, p = 0.008). Both techniques showed specificity and positive predictive value of 100%, and similar sensitivity (69% versus 75%, p = 0.45), negative predictive value (58% versus 38%, p = 0.15) and accuracy (78% versus 79%, p = 1.00). After IPTW, the diagnostic performance of the two techniques remained similar., Conclusion: Compared to EUS-FNA, PTC-EFB provides similar sensitivity, negative predictive value and accuracy. It should therefore be considered as the preferred tissue-sampling procedure, if biliary drainage is indicated., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background & Aims: A proportion of patients with Budd-Chiari Syndrome (BCS) associated with stenosis or short occlusion of the hepatic vein (HV) or upper inferior vena cava (IVC) can be treated with recanalization by percutaneous venoplasty ± HV stent insertion. We studied the long-term outcomes of this approach., Methods: Single-centre retrospective analysis of patients referred for radiological assessment ± intervention over a 27-year period. Of 155 BCS patients, 63 patients who underwent venoplasty were studied and compared to a previously reported series treated by TIPSS (n = 59)., Results: Patients treated with HV interventions (32 venoplasty alone, 31 endovascular stents): mean age, 34.9 ± 10.9; M:F ratio 27:36; median follow-up, 113.0 months; 62% of patients had ≥1 haematological risk factor. Technical success was 100%, with symptom resolution in 73%. Cumulative secondary patency at 1, 5, 10 years was 92%, 79%, 79% and 69%, 69%, 64% in the stenting and venoplasty groups respectively. Where long-term patency was not achieved, 10 patients required TIPSS, and 8 underwent surgery. Actuarial survival at 1, 5, 10 years was 97%, 89% and 85%. When compared to TIPSS, HV interventions resulted in similar patency and survival rates but significantly lower procedural complications (9.5% vs 27.1%) and hepatic encephalopathy (0% vs 18%). Patient age predicted survival following multivariate analysis., Conclusions: Our data support the stepwise approach to management of BCS, with very good outcomes from venoplasty combined with stenting when required. TIPSS should only be offered where HV interventions are not feasible or unsuccessful., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Hepatic venous outflow obstruction (HVOO) is a rare complication after liver transplantation (LT) associated with significant morbidity and reduced graft survival. Endovascular intervention has become the first-line treatment for HVOO, but data on long-term outcomes are lacking. We have analysed outcomes after endovascular intervention for HVOO in 905 consecutive patients who received 965 full-size LT at our unit from January 2007 to June 2014. There were 27 (3%) patients who underwent hepatic venogram for suspected HVOO, with persistent ascites being the most common symptom triggering the investigation (n = 19, 70%). Of those, only 10 patients demonstrated either stricture or pressure gradient over 10 mmHg on venogram, which represents a 1% incidence of HVOO. The endovascular interventions were balloon dilatation (n = 3), hepatic vein stenting (n = 4) and stenting with dilatation (n = 3). Two patients required restenting due to stent migration. The symptoms of HVOO completely resolved in all but one patient, with a median follow-up period of 74 (interquartile range 39-89) months. There were no procedure-related complications or mortality. In conclusion, the incidence of HVOO in patients receiving full-size LT is currently very low. Endovascular intervention is an effective and safe procedure providing symptom relief with long-lasting primary patency., (© 2016 Steunstichting ESOT.)

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Various factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF., Methods: A post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2 :1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set., Results: Postoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768-0.897; P < 0.001) and successfully tested upon the validation set., Conclusions: Preoperative assessment of a patient's risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD., (© 2013 International Hepato-Pancreato-Biliary Association.)