Intravenous omega-3 fatty acids are associated with better clinical outcome and less inflammation in patients with predicted severe acute pancreatitis: A randomised double blind controlled trial.

BACKGROUND AND AIMS: Omega-3 fatty acids (FA) can ameliorate the hyper-inflammatory response that occurs in conditions such as severe acute pancreatitis (SAP) and this may improve clinical outcome. We tested the hypothesis that parenteral omega-3 FA from a lipid emulsion that includes fish oil could be beneficial in patients with predicted SAP by reducing C-reactive protein (CRP) concentration (primary outcome), and modulating the inflammatory response and improving clinical outcome (secondary outcomes). METHODS: In a phase II randomized double-blind single-centre controlled trial, patients with predicted SAP were randomised to receive a daily infusion of fish oil containing lipid emulsion (Lipidem® 20%, BBraun) for 7 days (n = 23) or a daily infusion of a lipid emulsion without fish oil (Lipofundin® MCT 20%, BBraun) (n = 22). RESULTS: On admission, both groups had comparable pancreatitis predicted severity and APACHE II scores. Administration of fish oil resulted in lower total blood leukocyte number (P = 0.04), CRP (P = 0.013), interleukin-8 (P = 0.05) and intercellular adhesion molecule 1 (P = 0.01) concentrations, multiple organ dysfunction score, sequential organ failure assessment score (P = 0.004), early warning score (P = 0.01), and systemic inflammatory response syndrome (P = 0.03) compared to the control group. The fish oil group had fewer new organ failures (P = 0.07), lower critical care admission rate (P = 0.06), shorter critical care stay (P = 0.03) and shorter total hospital stay (P = 0.04). CONCLUSIONS: It is concluded that intravenous administration of a fish oil containing lipid emulsion, a source of omega-3 FA, improves clinical outcomes in patients with predicted SAP, benefits that may be linked to reduced inflammation. CLINICALTRIALS. GOV NUMBER: NCT01745861. EU CLINICAL TRIALS REGISTER: EudraCT (2010-018660-16).

Treatment Access and Survival Amongst British Asians with Pancreatic Cancer.

INTRODUCTION: Despite increasingly mixed communities in large cities, there remains a paucity of absolute and comparative data concerning the treatment, access and survival of British Asians with pancreatic cancer. METHODS: A prospective database of 1038 patients with a diagnosis of pancreatic cancer from 2003 to 2012 was analysed. Asian/Asian British was defined as patients identifying themselves as originating from India, Bangladesh or Pakistan. RESULTS: No significant difference was observed in gender split for both Asian/Asian British and White British (AAB and WB). The incidence of pancreas cancer was also equivalent between the two groups at 8.1 versus 8.8 per 100,000 of the population. Age at presentation was significantly younger in AABs when compared to WBs (67 vs. 70 years, p = 0.003). Whilst median maximal tumour diameter, node status and the incidence of metastases were not different between AABs and WBs, the AABs had a significantly greater median T-stage (3.0 versus 2.5, p = 0.0024). The percentage of patients referred for chemotherapy was significantly higher in the AAB group (70.5 vs. 47.7 %, p = 0.0015). Overall survival and survival for patients having palliative treatment were significantly greater in AABs (4.6 vs. 6.1 months and 3.7 vs. 5.1 months). CONCLUSION: This study demonstrates that AAB patients are present with pancreatic cancer at a younger age and that when receiving palliative chemotherapy their survival is significantly better. Further studies and larger data sets over a longer period are required. It is important to examine further the complexity of incidence and survival in ethnic minorities and investigate the underlying reasons when differences are demonstrated.

Role of preoperative carbohydrate loading: a systematic review.

INTRODUCTION: Surgical stress in the presence of fasting worsens the catabolic state, causes insulin resistance and may delay recovery. Carbohydrate rich drinks given preoperatively may ameliorate these deleterious effects. A systematic review was undertaken to analyse the effect of preoperative carbohydrate loading on insulin resistance, gastric emptying, gastric acidity, patient wellbeing, immunity and nutrition following surgery. METHODS: All studies identified through PubMed until September 2011 were included. References were cross-checked to ensure capture of cited pertinent articles. RESULTS: Overall, 17 randomised controlled trials with a total of 1,445 patients who met the inclusion criteria were identified. Preoperative carbohydrate drinks significantly improved insulin resistance and indices of patient comfort following surgery, especially hunger, thirst, malaise, anxiety and nausea. No definite conclusions could be made regarding preservation of muscle mass. Following ingestion of carbohydrate drinks, no adverse events such as apparent or proven aspiration during or after surgery were reported. CONCLUSIONS: Administration of oral carbohydrate drinks before surgery is probably safe and may have a positive influence on a wide range of perioperative markers of clinical outcome. Further studies are required to determine its cost effectiveness.

Cellular and plasma uptake of parenteral omega-3 rich lipid emulsion fatty acids in patients with advanced pancreatic cancer.

BACKGROUND & AIMS: Omega-3 rich fatty acids (n-3FA) have powerful anti-inflammatory and anti-neoplastic properties. Previous studies have investigated plasma and cellular uptake of oral and parenteral n-3FA regimens. These have shown that n-3FA undergo rapid uptake into cells which is sustained for the length of the treatment course. The aim of this study was to investigate long-term uptake of prolonged, regular treatment courses of parenteral n-3FA which has not been previously reported. METHODS: As part of a phase II single-arm trial, patients with advanced pancreatic cancer were treated with gemcitabine plus parenteral n-3FA rich lipid emulsion (up to 100 g) each week for three consecutive weeks with a subsequent rest week. This was repeated for up to six months in total for each patient. Pre-treatment serum and erythrocyte cell membrane (ECM) pellet samples were obtained each week for the entire treatment course of each patient. Post-treatment samples were obtained for the first two cycles only to assess rapid uptake. Fatty acid methyl esters (FAME) were produced and analysed using gas chromatography. FAME proportions as a total of sample lipid composition for each class were plotted and the results analysed using a linear regression coefficient model. RESULTS: There was rapid and significant uptake of EPA and DHA FAME into plasma Non-Esterified Fatty Acids (NEFA) and EPA into ECM pellets in post-treatment samples (median increase of 1.06%, 0.65% and 0.05% respectively). There was significant reduction in n-6 fatty acid FAMEs and DHA in ECM pellets (decrease of 0.31% and 0.8% respectively- p = 0.031 for all). There was significant sustained uptake of EPA and DHA FAME into ECM pellets over the cohort's pooled treatment course with corresponding reduction in the n-6:n-3 ratio. CONCLUSIONS: Prolonged regular parenteral n-3FA administration results in rapid and sustained cellular uptake. This regimen is appropriate for therapies aimed at increasing n-3FA content of cellular membranes and reduction of the n-6:n-3 ratio.

The role of magnetic resonance cholangiopancreatography in the management of acute gallstone pancreatitis.

INTRODUCTION: The aim of this study was to identify whether magnetic resonance cholangiopancreatography (MRCP) can be used selectively in patients with acute gallstone pancreatitis to detect choledocholithiasis, based on liver function tests (LFTs) and ultrasonography appearance. METHODS: All patients admitted between January 2008 and January 2011 with gallstone pancreatitis (amylase >300u/l) who underwent MRCP were included in the study. LFTs and radiology reports were obtained from the respective computer systems. RESULTS: Overall, 173 patients with acute gallstone pancreatitis underwent MRCP and 30% (52/173) showed choledocholithiasis. The mean bilirubin level was significantly higher in those with choledocholithiasis (46 ±5µmol/l vs 36 ±3µmol/l, p=0.0388) although there was no significant difference in alkaline phosphatase (276 ±25iu/l vs 229 ±16iu/l, p=0.1154). However, sensitivity of abnormal bilirubin (>21µmol/l) for choledocholithiasis was only 62% and specificity was 41%. Sensitivity of abnormal alkaline phosphatase (>140iu/l) for choledocholithiasis was only 75% and specificity was 37%. There was a significant association between biliary dilatation on ultrasonography and choledocholithiasis on MRCP (p=0.0099) although the sensitivity of biliary dilatation for choledocholithiasis was only 44% and the specificity was 79%. Furthermore, there was no difference in the incidence of choledocholithiasis on MRCP for those patients with persistently deranged LFTs versus those whose LFTs returned to normal (relative risk: 1.07, 95% confidence interval: 0.61-1.89, p=1.00). Overall, 10% of patients with choledocholithiasis on MRCP had entirely normal LFTs on admission and no biliary dilatation or choledocholithiasis on ultrasonography. CONCLUSIONS: All patients with acute gallstone pancreatitis should undergo specific imaging, preferably MRCP, to exclude choledocholithiasis as LFTs and ultrasonography are inaccurate in predicting common bile duct stones.

Changing trends in the presentation of colorectal liver metastases in a single hepatobiliary tertiary referral centre over fourteen years.

AIM: National Institute for Clinical Excellence guidelines suggest that patients who have undergone potentially curative treatment for colorectal cancer (CRC) should be followed up for 3 years. The aim of this study was to investigate whether the time to presentation with colorectal liver metastases (CRLM) has changed over time. This information, which is currently unknown, may inform future decisions regarding follow-up. METHODS: Patients presenting with metachronous isolated liver metastases between 1997 and 2011 were included. Timings of presentation with CRLM, rates of liver resection, survival data and factors associated with delayed presentation were investigated. RESULTS: 269 patients were included in the study. Those having their primary CRC resection between 1997 and 2007 presented earlier with liver metastases over time (r = -0.33, 95% CI -0.45 to -0.20). However, 26% of patients who developed CRLM did so beyond 3 years. There was no significant difference in rates of liver resections for those presenting within, or beyond, 3 years (p = 0.21). There was no significant difference in survival for those presenting with resectable CRLM within, or beyond, 3 years (Exp(b) = 0.60, 95% CI 0.28-1.28). No factors associated with late presentation were identified. CONCLUSIONS: These results suggest that CRC follow-up should be extended to 5 years. Follow-up interventions should be more frequent in the early stages reflecting the trend towards earlier presentation with CRLM. The economic implications of extending follow-up compare favourably to other NHS funded initiatives.

The differential effects of statins on the risk of developing pancreatic cancer: a case-control study in two centres in the United Kingdom.

INTRODUCTION: There are plausible biological mechanisms for how statins may prevent pancreatic cancer, although the evidence from epidemiological studies in the general population is conflicting. This study aims to clarify whether statins exert their effects in specific sub-groups, namely, gender, smoking status and diabetes. METHODS: A matched case-control study was conducted in patients diagnosed with pancreatic cancer, and a group of dermatology patients of similar ages and gender, diagnosed with basal cell carcinoma. Participants' medical records were reviewed for information on statin use prior to diagnosis. Odds ratios and 95 % CIs for the development of pancreatic cancer were estimated using conditional logistic regression. Subgroup analysis was performed in men, women, smokers and those with type 2 diabetes. RESULTS: Two hundred fifty-two cases (median age 71 years, range 48-73 years, 51 % women) and 504 controls were identified, of which 23 % of cases were regular statin users versus 21 % of controls. In the general study population there was no association between pancreatic cancer and regular statin use (OR 0.82, 95 % CI 0.53-1.23, p = 0.33). However, in male smokers, regular statin use was associated with significantly reduced odds of pancreatic cancer compared to male smokers not prescribed a statin (OR 0.11, 95 % CI 0.01-0.96, p = 0.05). In patients with type 2 diabetes statins use was not associated with reduced odds (OR 0.92, 95 % CI 0.35-2.45, p = 0.80), with no gender effects. CONCLUSIONS: In male smokers, statins may reduce the odds of pancreatic cancer. Statin use should be measured in aetiological studies of pancreatic cancer but analysed in specific sub-groups. Future work should investigate statins as chemopreventative agents in this high risk sub-group.

Imaging of indeterminate pancreatic cystic lesions: a systematic review.

BACKGROUND: Pancreatic cystic lesions are an increasing problem and investigation of these cysts can be fraught with difficulty. There is currently no gold standard for diagnosis or surveillance. This review was undertaken to determine the present reliability of the characterisation, assessment of malignant potential and diagnosis of pancreatic cystic lesions using available imaging modalities. METHODS: A Medline search using the terms 'pancreatic', 'pancreas', 'cyst', 'cystic', 'lesions', 'imaging', 'PET'. 'CT', 'MRI' and 'EUS' was performed. Publications were screened to include studies examining the performance of CT, MRI, MRCP, EUS and 18-FDG PET in the determination of benign or malignant cysts, cyst morphology and specific diagnoses. RESULTS: Nineteen studies were identified that met the inclusion criteria. 18-FDG PET had a sensitivity and specificity of 57.0-94.0% and 65.0-97.0% and an accuracy of 94% in determining benign versus malignant cysts. CT had a sensitivity and specificity of 36.3-71.4% and 63.9-100% in determining benign disease but had an accuracy of making a specific diagnosis of 39.0-44.7%. MRI had a sensitivity and specificity of 91.4-100.0% and 89.7% in assessing main pancreatic duct communication. CONCLUSION: CT is a good quality initial investigation to be used in conjunction with clinical data. MRCP can add useful information regarding MPD communication but should be used judiciously. PET may have a role in equivocal cases to determine malignancy. Further examination of CT-PET in this patient group is warranted.

The multifaceted effects of omega-3 polyunsaturated Fatty acids on the hallmarks of cancer.

Omega-3 polyunsaturated fatty acids, in particular eicosapentaenoic acid, and docosahexaenoic acid have been shown to have multiple beneficial antitumour actions that affect the essential alterations that dictate malignant growth. In this review we explore the putative mechanisms of action of omega-3 polyunsaturated fatty acid in cancer protection in relation to self-sufficiency in growth signals, insensitivity to growth-inhibitory signals, apoptosis, limitless replicative potential, sustained angiogenesis, and tissue invasion, and how these will hopefully translate from bench to bedside.

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review.

INTRODUCTION: The terms 'enhanced recovery after surgery', 'enhanced recovery programme' (ERP) and 'fast track surgery' refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery. METHODS: A MEDLINE ® literature search was undertaken using the keywords 'enhanced recovery', 'fast-track', 'peri-operative', 'surgery', 'pancreas' and 'liver' and their derivatives such as 'pancreatic' or 'hepatic'. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate. RESULTS: Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study. CONCLUSIONS: The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.

Factors predicting significant pathology on ultrasonography in women presenting with non-specific lower abdominal pain.

INTRODUCTION: Ultrasonography is used frequently to exclude significant pathology in young women presenting with non-specific lower abdominal pain (NSLAP). This study examined parameters that predicted the likelihood of significant findings on ultrasonography. These results could be used to select patients for priority imaging or identify those who could be managed with no ultrasonography. METHODS: A total of 65 women with NSLAP were identified from 283 admissions. Group 1 (n=42) consisted of patients with normal imaging. Group 2 (n=23) included patients with 'positive' scans requiring treatment. White cell count (WCC), C-reactive protein (CRP) levels, platelet count, age, duration of pain and length of stay in hospital were compared between the groups. RESULTS: The median WCC and CRP were greater in Group 2 than in Group 1: 15 x 10(9)/l and 123 mg/l versus 11 x 10(9)/l and 72 mg/l respectively (p=0.01 and p=0.05). CRP was a weak predictor of positive pathology on ultrasonography (area under curve [AUC]=0.66, p=0.027) and WCC was a strong predictor of abnormal pathology on ultrasonography (AUC=0.7, p=0.005). A WCC of >12.8 x 10(9)/l was 65% sensitive and 71% specific in predicting subsequent pathology on ultrasonography. The median wait for ultrasonography was 24 hours (range: 1-96 hours). CONCLUSIONS: This study failed to define any criteria that could select patients not requiring ultrasonography. Since ultrasonography is a relatively cheap and safe investigation, its continued use to screen women with NSLAP is justified. WCC should be used to prioritise imaging.

Preoperative neutrophil-to-lymphocyte ratio (NLR) is associated with reduced disease-free survival following curative resection of pancreatic adenocarcinoma.

BACKGROUND: Serological proinflammatory markers such as C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) have been associated with reduced survival for many different types of cancer. This study determined the prognostic value of the preoperative value of these markers in patients with resectable pancreatic adenocarcinoma. METHODS: Consecutive patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were entered into our database from 2001 to the present day. CRP, NLR, and PLR at the time of presentation were recorded as well as overall and disease-free survival. RESULTS: Seventy-four patients were identified. Overall median survival was 35.0 months and median disease-free survival was 27.0 months. Follow-up ranged from 1 to 125.8 months. Preoperative NLR was significantly greater in those patients who developed recurrence in the follow-up period (4.5 vs. 3.1). CRP and PLR were not found to differ significantly between the two groups. Kaplan-Meier survival analysis of patients with NLR > 5 demonstrated a disease-free survival of 12 months compared with 52 months for those patients with NLR < 5 (p < 0.001). CONCLUSION: Preoperative NLR offers important prognostic information regarding disease-free survival following curative resection of pancreatic ductal adenocarcinoma.

Experimental application of electrolysis in the treatment of liver and pancreatic tumours: principles, preclinical and clinical observations and future perspectives.

BACKGROUND: Electrolytic ablation (EA) is a treatment that destroys tissues through electrochemical changes in the local microenvironment. This review examined studies using EA for the treatment of liver and pancreatic tumours, in order to define the characteristics that could endow the technique with specific advantages compared with other ablative modalities. METHODS: Literature search of all studies focusing on liver and pancreas EA. RESULTS: A specific advantage of EA is its safety even when conducted close to major vessels, while a disadvantage is the longer ablation times compared to more frequently employed techniques. Bimodal electric tissue ablation modality combines radiofrequency with EA and produced significant larger ablation zones compared to EA or radiofrequency alone, reducing the time required for ablation. Pancreatic EA has been investigated in experimental studies that confirmed similar advantages to those found with liver ablation, but has never been evaluated on patients. Furthermore, few clinical studies examined the results of liver EA in the short-term but there is no appropriate follow-up to confirm any survival advantage. CONCLUSIONS: EA is a safe technique with the potential to treat lesions close to major vessels. Specific clinical studies are required to confirm the technique's safety and eventually demonstrate a survival advantage.

The effects of radiofrequency ablation on the hepatic parenchyma: histological bases for tumor recurrences.

BACKGROUND: This review examines histological modifications obtained after liver radiofrequency ablation (RFA). METHODS: A literature search has been undertaken for all pre-clinical and clinical studies involving RFA and in which ablation zones have been excised for a complete histological examination. RESULTS: Two main histological areas are present, a central zone of coagulative necrosis and a peripheral rim of congestion and extravasation. Both corresponded to specific microscopic characteristics that evolved over time and that are influenced by the proximity of patent vessels and the liver perfusion status. Viable cells are not present in the central zone but have been described in the ischemic peripheral rim where they survive the ischemia and inflammation process. These correspond in clinical studies to residual viable tumor cells that lead to failure of the procedure. CONCLUSIONS: Histological changes following RFA are complex and interactions take place at both a cellular and tissue level. Changes in the peripheral zone must be considered in future studies in order to extend the volume of reliable tumor destruction and increase the effectiveness of the procedure.

Prediction of mortality in acute pancreatitis: a systematic review of the published evidence.

OBJECTIVE: In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis. SUMMARY BACKGROUND DATA: Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality. METHODS: All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded. RESULTS: 58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power. CONCLUSIONS: Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.

Cytokine response to ischemia/reperfusion injury in an ex vivo perfused porcine liver model.

BACKGROUND: We evaluated the degree of inflammatory response after ischemia/reperfusion injury by an extracorporeal normothermic autologous hemoperfusion of porcine livers. MATERIALS AND METHODS: Livers explanted from 7 pigs were perfused extracorporeally at 39 degrees C with autologous blood. Serum samples were obtained hourly until 6 hours from the beginning of reperfusion and assayed for 9 different cytokines. RESULTS: Significant elevations in interleukin 6 (IL-6) and IL-8 were noted following reperfusion (P < .001), with both demonstrating an increase which followed a sigmoid curve; other cytokines that were assessed showed no significant change. CONCLUSIONS: The ex vivo model excludes the liver from the influence of external systemic factors such as hormones, the autonomic nervous system, and other regulatory molecules produced elsewhere in the body, allowing the response to the ischemia/reperfusion injury to be studied in isolation and in considerable detail. Although this study examined a relatively short period, the increases in only IL-6 and IL-8 suggested that these are important molecules in the early phase after reperfusion.

Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants.

BACKGROUND: Function and survival of non-heart-beating donor (NHBD) renal transplants have been shown to be comparable to those from heart-beating donors (HBDs) up to 10 years after transplantation. However, there are few data on outcome after 10 years, particularly from uncontrolled NHBD donors. METHODS: All NHBD renal transplants (predominantly uncontrolled) performed between April 1992 and January 2002 were retrospectively matched with HBD renal transplants performed over the same period. RESULTS: Some 112 NHBD renal transplants were compared with 164 HBD renal transplants. Delayed graft function was significantly higher in the NHBD group (83.9 versus 22.0 per cent respectively; P < 0.001). Primary non-function rates were similar (5.4 versus 1.8 per cent respectively; P = 0.164). Overall serum creatinine was significantly higher in NHBDs (P < 0.001). Median graft and patient survival was 126 months for NHBD and 159 months for HBD kidneys. Death-censored graft survival at 1, 5, 10 and 15 years was respectively 91.8, 77.5, 61.0 and 44.2 per cent for NHBD, and 91.1, 86.3, 71.7 and 58.5 per cent for HBD kidneys (P = 0.108). CONCLUSION: Despite increased delayed graft function rates and serum creatinine levels, the long-term survival of NHBD renal transplants was similar to those from HBDs. However, there was a trend to poorer function and survival from 10 years after transplant.

Elevation of carbohydrate antigen 19.9 in benign hepatobiliary conditions and its correlation with serum bilirubin concentration.

BACKGROUND: Carbohydrate antigen 19.9 (CA19.9), a tumor marker for malignancies of the hepatobiliary tract and pancreas, has frequently been shown to be deranged in a number of non-malignant conditions that are associated with jaundice. This study aims to demonstrate the correlation between CA19.9 and serum bilirubin concentration in patients with benign conditions and to determine the frequency of a false-positive increase in CA19.9 in patients being investigated for potential HPB malignancies. METHODS: This is a retrospective review of 83 consecutive patients presenting with an abnormal CA19.9 and radiological or clinical features suggestive of HPB malignancy subsequently shown to have benign disease. All patients were thoroughly investigated and followed up until the diagnosis of malignancy could be safely excluded. RESULTS: Serum bilirubin, sodium, lymphocyte count, neutrophil:lymphocyte ratio (NLR), beta-human chorionic gonadotrophin (HCG), and age were found to correlate with CA19.9 by Pearson's correlation (P = 0.001, P = 0.006, P = 0.006, P < 0.001, P = 0.012, and P = 0.049, respectively). In multivariate regression analysis, bilirubin was identified as an independent variable that may predict CA19.9 level (P = 0.028). CONCLUSION: CA19.9 level is significantly influenced by serum bilirubin and elevated levels have been observed in patients with non-malignant HPB conditions. Adjusting CA19.9 according to bilirubin levels is likely to improve the specificity of this antigen in the differential diagnosis of benign and malignant HPB diseases and its reliability in the monitoring of disease response to chemotherapy.

Major resection of hepatic colorectal liver metastases in elderly patients - an aggressive approach is justified.

AIMS: With a progressively ageing population, increasing numbers of elderly patients will present with colorectal metastases and be referred for surgical resection. The aim of this study was to assess the safety of hepatic resection in patients over 70 years of age by comparing outcomes with those of a younger cohort of patients. METHODS: Forty-nine patients over 70 years of age who underwent hepatic resection of colorectal liver metastases were compared to 142 patients less than 70 years of age in terms of pre-, peri- and post-operative results, as well as long-term survival. RESULTS: Major resections were performed in 61% of the elderly group and 68% of the younger group. The two groups were comparable in terms of operative duration, transfusion rate, length of HDU stay and post-operative hospital stay. The elderly group had a non-significant increase in post-operative morbidity. The 30-day and 60-day/inpatient mortality rates were similar between the two groups (elderly 0% and 4%; younger 2% and 3%). Long-term disease-free survival was similar between elderly and younger patients. CONCLUSION: This study confirms that an aggressive surgical policy towards colorectal metastases in elderly patients is associated with low peri-operative morbidity and mortality, as well as good long-term outcomes.

Role of ultrasonography in the detection of resectable recurrence after hepatectomy for colorectal liver metastases.

BACKGROUND: Recurrence develops in most patients after hepatectomy for colorectal liver metastases. Repeat resection is feasible in some of these patients. The aim of this study was to evaluate an ultrasound-based follow-up protocol in the detection of resectable recurrent disease. METHODS: All patients undergoing hepatectomy for colorectal liver metastases at a single hepatobiliary referral centre in the UK from January 1999 to December 2004 were identified. Variables reviewed included rates of recurrence, mode and timing of detection, rates of repeat hepatectomy and survival. RESULTS: During the study period 191 patients underwent initial resection of colorectal liver metastases, of whom 109 developed recurrent disease. In total, 21 patients underwent potentially curative intervention, including 16 hepatic resections, four pulmonary resections and one staged pulmonary/hepatic resection. Ten of 72 patients who presented with recurrent disease within 12 months after initial resection were amenable to curative resection, compared with 11 of 37 patients presenting after 12 months. Sonographic surveillance identified all of the potentially resectable recurrent hepatic disease in the series. CONCLUSION: Ultrasonography is effective in the detection of potentially resectable hepatic recurrence after hepatectomy for colorectal liver metastases; however, routine chest imaging is needed.