What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION: Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center. METHODS: We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC. RESULTS: Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone. CONCLUSIONS: PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Neutrophil to lymphocyte ratio predicts perioperative mortality following open elective repair of abdominal aortic aneurysms.

OBJECTIVES: This study assesses the predictive value of neutrophil to lymphocyte ratio (NLR) in relation to 30-day and overall mortality following open abdominal aortic aneurysm (AAA) repairs. In addition, it assess assesses any correlation between NLR and age, size of the AAA and gender. METHODS: Patients undergoing elective or urgent open repair of their AAA by a single surgeon during a 10-year period were included. A pre-operative NLR of >5 was regarded as abnormal. RESULTS: 350 consecutive patients underwent AAA repair. 52 had an NLR>5. 30-day mortality rate was 12/52 (23%) in the NLR>5 group and 20/298 (6.7%) in the NLR<5 group (p = 0.0007). All deaths in the NLR>5 group were due to myocardial infarction. The median NLR was higher in those that died within 30 days at 4.2 [IQR: 2.6-7.5] versus 2.8 [IQR: 2.1-3.8] (p = 0.0001). Overall mortality at 10 years, in the NLR>5 group - 26/52 (50%) was significantly greater than that of the NLR<5 group - 102/298 (34.2%) (p = 0.043). Median NLR of those dying during follow-up was significantly higher in those with a baseline NLR>5 at 3.2 (IQR 2.5-4.6) versus 2.6 (IQR: 2.0-3.6) in those surviving (p = 0.00004). No difference was found between NLR and age, aneurysm size or gender. CONCLUSION: Pre-operative NLR>5 appears to be a significant predictor of both 30-day mortality and long-term outcome in elective and urgent open AAA surgery. It is plausible the NLR is identifying a group with sub-clinical cardiovascular disease at risk of peri-operative myocardial infarction.

Nodular regenerative hyperplasia (NRH) complicating oxaliplatin chemotherapy in patients undergoing resection of colorectal liver metastases.

INTRODUCTION: Sinusoidal obstructive syndrome (SOS) is well associated with the use oxaliplatin-based chemotherapy, and represents a spectrum of hepatotoxicity, with nodular regenerative hyperplasia (NRH) representing the most significant degree of injury. The aim of this study was to determine the prevalence of NRH in patients undergoing resection of colorectal liver metastases (CRLM) and to determine its impact on outcome. METHODS: From January 2000 to December 2010, some 978 first primary liver resections were performed for CRLM. A prospectively maintained database was analysed to identify all patients with evidence of NRH in the non-tumour portion of their histopathology specimens. Clinical data of these patients was reviewed and outcomes assessed. RESULTS: Five patients exhibited NRH (four males, one female) with a median age of 69 years (range: 35-74). Three patients presented with synchronous hepatic metastases, and two with metachronous lesions. All received at least 6 cycles of oxaliplatin as either adjuvant or neo-adjuvant chemotherapy. Only one patient developed a post-operative complication namely transient hepatic failure that required a 4-day stay in the intensive care unit. The median hospital stay was 6 days (range: 6-14 days). There were no 90-day mortalities. One patient is alive and disease free at 55 months, the remaining 4 died of recurrent disease between 37 and 70 months following diagnosis of their primary tumours. CONCLUSIONS: NRH is not an uncommon finding amongst patients with SOS with all patients having received oxaliplatin-based chemotherapy. Data on outcome would suggest no increased morbidity and mortality associated with the presence of NRH.

Internal carotid artery occlusion: its natural history including recanalization and subsequent neurological events.

OBJECTIVE: To determine the incidence of recanalization of the occluded internal carotid artery (ICA) and establish its natural history. METHODS: Patients with duplex-confirmed ICA occlusions were identified, and a subgroup offered repeat scanning. The antemortem condition and cause of death of patients who died were recorded. RESULTS: Of 153 patients identified, 77 underwent follow-up at a median of 35 months (interquartile range [IQR]: 14-61).In all, 8 (10.3%) demonstrated recanalization at a median of 53 months (IQR: 35-114). Of 8, 7 underwent carotid endarterectomy with histopathological confirmation of recanalization. Of the 153 patients, 45 (29%) had further neurological events, and 38 (25%) were within the territory of the occluded ICA. In all, 76 patients died, and of the 53 with a confirmed cause of death, 12 (23%) were attributed to a cerebrovascular accident corresponding to the territory of the occluded artery. CONCLUSION: Recanalization of ICA occlusion is common and leads to significant neurological events. Duplex ultrasound follow-up appears mandatory.

A selective antibiotic prophylaxis policy for laparoscopic cholecystectomy is effective in minimising infective complications.

INTRODUCTION: It has been demonstrated previously that the identification of bactibilia during cholecystectomy is associated with the presence of one or more risk factors: acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age >70 years. Current evidence-based guidance on antibiotic prophylaxis during laparoscopic cholecystectomy (LC) is based on elective procedures and does not take into account these factors. The aim of this study was to assess the effectiveness of a selective antibiotic prophylaxis policy limited to high risk patients undergoing LC with the development of port site infections as the primary endpoint. METHODS: One hundred consecutive patients undergoing LC under the care of a single consultant surgeon during a one-year period were studied prospectively. Data collected included patient demographics (age, sex) as well as details of the history of gallstone disease to determine those with complex disease and risk factors for bactibilia. A single dose of antibiotics (second generation cephalosporin and metronidazole) was administered on induction to patients with a risk factor present. Information relating to all radiologically or microbiologically confirmed infections was documented. RESULTS: Eighty-four of the patients were female and the mean age was 47.7 ±16.0 years. Nineteen LCs were performed as emergencies and the remainder were elective procedures. A risk factor for bactibilia was present in 35 patients. A wound infection was identified in four cases, two of which were Staphylococcus aureus (one methicillin resistant), one was a coagulase negative Staphylococcus and one wound cultured a mixed anaerobic growth. Three of the infections occurred in patients receiving prophylaxis (2 staphylococcal and 1 anaerobic) at intervals of 7, 14 and 19 days respectively. One patient with a body mass index of 32kg/m² in the 'no prophylaxis' group developed a coagulase negative staphylococcal infection at 10 days. No intra or extra-abdominal abdominal infections were identified. CONCLUSIONS: This study has demonstrated that restricting antibiotic prophylaxis to high risk patients has no detrimental effects in terms of increasing the rate of infections in those with no risk factors. Furthermore, the act of not prescribing to low risk patients will limit costs and the risk of adverse events. It will also reduce the risk of resistance and clostridial infections in this cohort.

Acute pancreatitis in the elderly - Can we perform better?

BACKGROUND: Despite age traditionally being a criterion for stratification of severity in acute pancreatitis (AP), the condition is not common in the elderly population (>80 years) and very few studies have examined outcome in this cohort. The aim of this study was to evaluate our experience and outcome in this expanding population. METHODS: A retrospective analysis was performed of all patients over 80 years of age who were admitted with AP (defined as a serum amylase >400 IU/L) between January 2004 and January 2007. The modified Glasgow score was used for severity stratification. RESULTS: Forty patients with AP were admitted during the study period, of whom 23 were females. The mean age was 84 (SD 4.1) years. Fifteen patients (37%) had severe AP as indicated by a Glasgow score of 3 or more. The aetiologies were gallstones (n = 28; 70%), drug-induced (n = 4; 10%) and idiopathic (n = 8; 20%). Ten patients (25%) died during their initial admission to hospital, of whom 5 died before undergoing any form of imaging to determine the cause of AP. Six patients, 5 of whom had gallstones were subsequently readmitted with a further attack of AP. Eleven patients underwent an ERCP during their initial admission and a further 4 patients underwent ERCP during their subsequent admission. Only 3 patients with gallstone-induced AP underwent a cholecystectomy, all performed laparoscopically. CONCLUSIONS: AP in octogenarians is a significant problem and carries a high mortality irrespective of the Glasgow severity score. Early intervention by means of ERCP is indicated to try and improve outcome in this group with biliary pancreatitis. Laparoscopic cholecystectomy must be considered as a definitive treatment in these patients as available evidence suggests that this can be performed with acceptable morbidity and mortality in this group.

Long-term clinical outcome following lower limb arterial angioplasty.

INTRODUCTION: The aim of this study was to determine the clinical outcome of lower limb arterial angioplasty in a busy district general hospital practice. PATIENTS AND METHODS: All angioplasties performed from January 1999 to December 2004 were identified and data collected included cardiovascular risk factors, indications for and complications of angioplasty, limb salvage and patient survival rates, and clinically significant re-stenoses. RESULTS: 471 interventions were performed in 385 patients (231 men, 154 women). The median age was 67.9 years (range: 39-93 years). Indications for angioplasty were critical ischaemia (n=247, 52%) and lifestyle-limiting intermittent claudication (n=224, 48%). Stenotic lesions accounted for 378 (80%) cases and occlusion for 93 (20%). Radiological success was obtained in 417 (88.5%), improving to 93.6% if only those in whom access was achieved were included. Post-angioplasty complications were observed in 42/471 (9.1%) of interventions. The actual patient survival at 1, 2, and 3 years was 87.4%, 85.1% and 83.2% respectively. Indication for angioplasty and the number of lesions present were identified as risk factors for outcome on multivariate analysis. The cumulative post-angioplasty patency rates at 1, 2 and 3 years were 86.0%, 83.1% and 81.6% respectively. The only factor associated with patency was the mode of presentation. CONCLUSIONS: Angioplasty for lower limb peripheral vascular disease can be performed safely and efficaciously with a high technical success rate and a low complication rate. The patient survival and post-angioplasty patency data reflect the progressive and multi-site nature of the underlying disease process.

Safety and application of laparoscopic gastrectomy for benign gastric disease and gastric cancer.

INTRODUCTION: Laparoscopic gastrectomy is rapidly expanding despite reservations by some surgeons regarding its safety and radicality. The aim of this study was to evaluate patients undergoing laparoscopic gastrectomy for both benign and malignant disease with particular emphasis on technical feasibility, safety, effectiveness and complications. PATIENTS AND METHODS: Review of prospectively collected data of patients who underwent laparoscopic gastrectomy from May 2005 to September 2009 under the care of one consultant surgeon. RESULTS: A total of 61 laparoscopic gastrectomies were performed (35 men and 26 women) with a median age of 68 years (range, 41-90 years). There were 39 distal gastrectomies (19 adenocarcinoma, 6 gastrointestinal stromal tumour [GIST], 4 benign gastric outlet obstruction, 4 high-grade dysplasia in gastric adenomas, 4 non-healing ulcers, 2 gastric antral vascular ectasia [GAVE]); 15 sub-total gastrectomies (13 adenocarcinomas, 2 GIST); and 7 total gastrectomies (5 adenocarcinomas, 1 GIST, 1 carcinoid). Median follow-up was for 48 months (range, 1-72 months). There was one death, two major and six minor complications. All patients with complications made a satisfactory recovery. CONCLUSIONS: Laparoscopic gastrectomy is associated with a low mortality (1.75%) and major morbidity (3.50%). Although technically demanding, especially when a D2 lymphadenectomy is performed, our results have shown that tailored laparoscopic resection based on tumour characteristics with either D1 or D2 lymphadenectomy results in good surgical and oncological outcomes.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases.

BACKGROUND: The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated. METHODS: Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated. RESULTS: Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds. CONCLUSION: Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources?

INTRODUCTION: It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain. PATIENTS AND METHODS: A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospectively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care. RESULTS: A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant. CONCLUSIONS: The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.

Extra-anatomical bypass grafting--a single surgeon's experience.

INTRODUCTION: Extra-anatomical bypass grafting is a recognised method of lower limb re-vascularisation in high-risk patients who cannot tolerate aortic cross clamping, or in those with a hostile abdomen. We present a single surgeon series of such procedures and determine relevant outcomes. PATIENTS AND METHODS: A retrospective review was performed on a prospectively maintained database of patients undergoing femoro-femoral or axillo-femoral bypass surgery between 1986 and 2004. RESULTS: Patency rates for femoral (n = 28; 32%) versus axillary (n = 59; 68%) bypass procedures at 1 month, 1, 3 and 5 years were (92% vs 93%), (69% vs 85%), (60% vs 72%) and (55% vs 67%), respectively. Patient survival rates for the corresponding procedures and time intervals were (96% vs 90%), (96% vs 67%), (85% vs 45%) and (73% vs 38%) and revealed a significantly lower survival rate in those undergoing axillary procedures (P = 0.002). Limb salvage rates were calculated at (100% vs 91%), (96% vs 84%), (96% vs 81%) and (92% vs 81%) with no statistically significant difference found between the two groups (P = 0.124). Two-thirds of the patients who required major amputation died within 12 months of surgery. CONCLUSIONS: Acceptable 30-day morbidity, long-term primary patency and survival rates are obtainable in patients suitable for extra-anatomical bypass surgery despite having significant co-morbidities. We have shown 5-year patency rates in those that survive axillary procedures to be as good as those undergoing femoral procedures. Furthermore, surviving patients who evade amputation within a year have an excellent chance of long-term limb salvage.

Appendico-colic fistula complicating appendicitis in cystic fibrosis.

The case of a boy with cystic fibrosis who presented with an unusual complication of appendicitis is reported. Delayed presentation, with complications of appendicitis such as perforation and abscess formation, is not uncommon in cystic fibrosis; however, this case represents the first report of an isolated appendico-colic fistula following appendicitis in association with cystic fibrosis.

Update experience of surgery for acute limb ischaemia in a district general hospital - are we getting any better?

INTRODUCTION: The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit. PATIENTS AND METHODS: All emergency operations performed during the period 1993-2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990. RESULTS: There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993-2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score > or = III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking. CONCLUSIONS: Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.

Assessment of survival advantage in ampullary carcinoma in relation to tumour biology and morphology.

INTRODUCTION: Carcinoma of the ampulla of Vater is said to carry a significantly better prognosis than pancreatic ductal adenocarcinomas arising in the pancreatic head. However, it is uncertain as to whether this is due to the fact that they have differing oncological characteristics or simply an earlier presentation as a result of the exophytic morphology of ampullary lesions causing obstruction of the bile ducts. METHODS: All patients undergoing pancreaticoduodenectomy between January 1998 and December 2004 were identified from a prospectively maintained database. Patients with a pathologically confirmed ampullary (AMP) tumour were compared to those with a carcinoma of the head of the pancreas (HOP). Tumour characteristics including size, stage and degree of differentiation were analysed as were survival data. RESULTS: 71 AMP and 144 HOP tumours were resected during the period studied and had full histology reports available for assessment. The median diameter of the AMP tumours was significantly less than those of the HOP (2 cm vs. 3 cm; p = 0.04). The T stage distribution differed significantly between the AMP and HOP tumours in favour of the former (Stages I--10 vs. 0 (p = 0.03); II--29 vs. 13 (p = 0.04); III--25 vs. 121 (p = 0.01); IV--7 vs. 10). The number of resection specimens with positive lymph nodes was lower in the AMP group (31 vs. 121; p = 0.03) as was the prevalence of vascular invasion (33 vs. 114; p = 0.006) and neural invasion (23 vs. 134; p = 0.009). There was no difference in the degree of differentiation of the AMP and HOP tumours. The 5-year survival rates were significantly better in the AMP group at 60% vs. 20% (p = 0.008). Subdivision of AMP carcinoma into polypoid (60%) and ulcerating (40%) lesions revealed a non-significant survival advantage in favour of polypoid tumours at (64% vs. 60%; p = 0.07) at 5 years. CONCLUSIONS: The outcome of resection for AMP is significantly better than for pancreatic ductal adenocarcinomas arising in the periampullary region. Although the anatomical position of AMP tumours may contribute to this survival advantage, the HOP tumours exhibit more adverse histological features suggesting that they are different diseases and hence the difference in survival.

Pleuropancreatic fistulae: specialist center management.

BACKGROUND AND AIMS: Internal pancreatic fistulae are uncommon sequelae of severe acute pancreatitis. Due to their low prevalence, experience in the management of this condition remains sparse outside specialist centers and management remains controversial. We report our experience with pleuropancreatic fistulae (PPF). PATIENTS: Six patients (three males, median age 34 years [range, 32-74 years]) with PPF were managed in our unit over a 24-month period from April 2006 to April 2008. The etiology of pancreatitis was alcohol (four), gallstones (one), and unknown cause (one). All patients had documented pleural effusions with amylase content >1,000 iu/dl. RESULTS: All patients underwent computerized tomography (CT) and magnetic resonance imaging (MRI) cross-sectional scanning to identify the site of ductal disruption. CT alone was able to identify the disruption in four cases and a combination of CT and MRI localized the ductal disruption in all patients. Five of six patients required ERCP and placement of a pancreatic duct (PD) stent. No patient required pancreatic surgery and all patients remain well at a median follow up of 39 weeks. CONCLUSION: Pleuropancreatic fistulae can present a challenging diagnostic dilemma. A multi-disciplinary approach addressing nutritional support and endotherapy allows successful non-operative resolution within specialist units.

Quantitative assessment of hepatic function and its relevance to the liver surgeon.

BACKGROUND: Standard evaluation of patients undergoing hepatic surgery has been through radiological and quantitative determination of liver function. As more complex and extensive surgery is now being performed, often in the presence of cirrhosis/fibrosis or following administration of chemotherapy, it is questioned whether additional assessment may be required prior to embarking on such surgery. The aim of this review was to determine the current knowledge base in relation to the performance of quantitative assessment of hepatic function both pre- and post-operatively in patients undergoing hepatic resectional surgery and liver transplantation. METHODS: An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles with cross-referencing of all identified papers to ensure full literature capture. RESULTS AND CONCLUSIONS: The review has identified a number of different methods of dynamically assessing hepatic function, the most frequently performed being through the use of indocyanine green clearance. With the recent and further anticipated developments in hepatic resectional surgery, it is likely that quantitative assessment will become more widely practiced in order to reduce post-operative hepatic failure and improve outcome.

Surgical management of hepatocellular carcinoma: is the jury still out?

INTRODUCTION: Hepatocellular carcinoma (HCC) is currently the fifth most common neoplasm worldwide. The only therapies which are capable of providing cure are hepatic resection and liver transplantation. Results from either resection or transplantation show 5-year survival rates of up to 70% in selected patients. Patient assessment is key to selecting candidates for surgery be it resection or transplantation. METHODS: A search was performed of the English Medline database for the period 1997-2006 using the MeSH headings: hepatocellular carcinoma, liver resection, and liver transplantation, with the main analysis concentrated on survival data for all patients undergoing resection or transplantation. RESULTS: There is a large variation in the mortality and recurrence rate following resection/transplantation due to differences in definition in different series. The median perioperative (30 day/in-hospital) mortality rate following resection was a median of 4.7%. The median 1, 3 and 5 year overall survival rates were 80.1%, 55% and 37.1%, respectively. The disease-free survivals at identical time intervals were 64%, 38% and 27%. The median 30 day mortality following liver transplant was 4.7% and the median 3-month mortality was 13.3%. The median overall 1, 3, and 5-year survival rates were 80.9%, 70.2% and 62%, respectively, whilst the disease-free survivals at identical time intervals were 79%, 62.5% and 54.5%. Several risk factors for overall and/or disease-free survival following resection and transplantation were found in those papers where a multivariate analysis was included. DISCUSSION: A possible algorithm would be to perform resection for patients with preserved liver function and offer transplantation to those of Child-Pugh status B or C who fit within Milan criteria. If recurrence occurred after resection or underlying liver disease progresses, salvage transplants may be performed. CONCLUSION: The current evidence base for resection and transplantation in the treatment of HCC is inadequate to provide a definite answer as to which is optimal therapy and a randomised controlled trial to compare the outcomes of resection and transplantation is now required.