Impact of Frailty on Short-Term Outcomes After Laparoscopic and Open Hepatectomy.

BACKGROUND: Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on post-operative outcomes after LH and OH. PATIENTS AND METHODS: Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail. RESULTS: Of 1826 patients, 34.7% (N = 634) were frail and 18.6% (N = 340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p < 0.001) and post-operative complications (36.3% vs. 26.1%, p < 0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients. CONCLUSIONS: Frailty is independently associated with inferior post-operative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.

Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort.

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

Liver resection and ablation for squamous cell carcinoma liver metastases.

BACKGROUND: Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS). METHOD: Members of the European-African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS. RESULTS: Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30). CONCLUSION: Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection.

Background: Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non-cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90-day mortality rates after liver resection. Methods: Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non-users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co-morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90-day mortality, significant postoperative complications and PHLF. Results: Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90-day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026). Conclusion: The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.

Outcomes of Sacral Nerve Stimulation For Faecal Incontinence in Northern Ireland.

BACKGROUND: Sacral nerve root stimulation (SNS) is an effective and developing therapy for faecal incontinence, a debilitating condition that can result in social and personal incapacitation. OBJECTIVES: The objectives of this study are to assess the morbidity of the procedure, improvement in the incontinence scores and Quality of Life (QoL) following SNS. MATERIALS AND METHODS: Patients were identified from the Northern Ireland regional SNS service from 2006 to 2012. Numbers of patients who had temporary placement and permanent placement were collated. Pre and postoperative assessment of severity of incontinence and QoL was performed using Cleveland Clinic Incontinence Score (CCIS) and Short Form-36 (SF-36) respectively. Statistical analysis was undertaken using Wilcoxon signed rank test. Morbidity was assessed by retrospective review of patient records. RESULTS: Seventy-five patients were considered for trial of a temporary SNS. Sixty-one proceeded to insertion of a temporary SNS and, of these, 40 elected to have a permanent SNS. There was a significant reduction in the pre-SNS and post-SNS Cleveland Clinic Incontinence Scores from median of 14 to 9 respectively (p=0.008). There was a significant improvement in Role Physical (p=0.017), General Health (p=0.02), Vitality (p=0.043), Social Functioning (p=0.004), Role Emotional (p=0.007), Mental Health (p=0.013) and Mental Health Summary (p=0.003). However, this is not reflected in the bodily pain and physical functional domains. CONCLUSION: Permanent sacral nerve stimulation is effective and results in significant improvement of faecal incontinence scores and quality of life.

Variations in Practice to Therapeutic Monitoring of Tacrolimus following Primary Adult Liver Transplantation.

BACKGROUND: There is limited clinical evidence evaluating the correlation between immunosuppressant monitoring practice and transplant outcomes. OBJECTIVE: To assess current practice of tacrolimus trough monitoring in early post-operative period following liver transplantation (LT), and its impact on outcomes. METHODS: The duration to trough levels (DTT) were calculated in patients undergoing primary LT. The impact of variability in DTT on graft rejection episodes, serum tacrolimus level and renal function was assessed. These results were converted into a drug level estimation tool, which was validated in a prospective cohort of patients. RESULTS: 2946 events in 274 patients were evaluated. The median DTT was 7:19 hrs (range: 27 min to 19:38 hrs). In 72% (2140 events) of the occasions, DTT was <8 hrs. There was a significant (p=0.022) correlation between DTT and tacrolimus level. Despite clinical decisions were taken to modify the dose of tacrolimus based on trough level, neither did DTT affect the average creatinine levels (p=0.923), nor the variability in DTT did affect acute rejection (p=0.914, and 0.712, respectively). A dose estimation tool was developed and applied to validation cohort (n=612), and returned a moderate R(2) value of 0.50. CONCLUSION: There is a significant variation in the "real world" monitoring of tacrolimus with DTT in majority of measurements falling below recommendations; reassuringly, this did not lead to adverse transplant sequelae.

Liposarcoma of the spermatic cord: a report of two cases.

Liposarcomas of the spermatic cord are unusual and rarely reported in the literature. These tumours can sometimes be mistaken for the common scrotal swellings such as hydrocoeles and hernias. Careful clinical and radiological examination will help in appropriate preoperative planning and surgery by an experienced surgical team. We report our experience of two cases of such scrotal swellings.

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction.

BACKGROUND: Use of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery. METHODS: Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates. RESULTS: Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management. CONCLUSION: Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality.

Assessment of complications following strictureplasty for small bowel Crohn's Disease.

BACKGROUND: Surgical intervention is required in a significant proportion of patients with small bowel Crohn's disease (CD). Strictureplasty is an effective bowel-sparing alternative to resection. AIM: The aim of this study is to assess the primary complications of small bowel strictureplasty for CD (bleeding and leakage). Other postoperative complications encountered, postoperative duration of hospital stay, 30-day mortality, and the incidence of reoperative surgery are also discussed. METHODS: A retrospective review of patients undergoing small bowel strictureplasty at The Royal Hospital between 1992 and 2007 was conducted. Twenty-seven patients underwent 34 laparotomies and 100 strictureplasties. RESULTS: There was no procedure-specific morbidity and mortality. Other common complications encountered were ileus (3/34) and surgical site infection (3/34). CONCLUSION: Most of the patients in this study have recurrent diffuse intestinal CD requiring synchronous bowel resection. Strictureplasty is a safe and effective bowel-sparing surgical option in this group of patients.

Intrahepatic delivery of feeds caused by a displaced percutaneous radiological gastrostomy catheter.

Percutaneous radiological gastrostomy (PRG) is a safe and accepted method of providing enteral nutrition in those with inadequate oral intake. We report a case of PRG that required laparotomy for intrahepatic displacement of a catheter that had been placed inadvertently through the liver under fluoroscopic guidance. Additional ultrasound or CT guidance may help to define a safe tract to avoid liver or colonic injury. Although transhepatic placement is reported to be well tolerated, this case raises concerns of additional morbidity associated with intrahepatic displacement.