Autofluorescence-Raman Spectroscopy for Ex Vivo Mapping Colorectal Liver Metastases and Liver Tissue.

INTRODUCTION: Identifying colorectal liver metastases (CRLM) during liver resection could assist in achieving clear surgical margins, which is an important prognostic variable for both disease-free and overall survival. The aim of this study was to investigate the effect of auto-fluorescence (AF) and Raman spectroscopy for ex vivo label-free discrimination of CRLMs from normal liver tissue. Secondary aims include exploring options for multimodal AF-Raman integration with respect to diagnosis accuracy and imaging speed on human liver tissue and CRLM. METHODS: Liver samples were obtained from patients undergoing liver surgery for CRLM who provided informed consent (15 patients were recruited). AF and Raman spectroscopy was performed on CRLM and normal liver tissue samples and then compared to histology. RESULTS: AF emission spectra demonstrated that the 671 nm and 775/785 nm excitation wavelengths provided the highest contrast, as normal liver tissue elicited on average around eight-fold higher AF intensity compared to CRLM. The use of the 785 nm wavelength had the advantage of enabling Raman spectroscopy measurements from CRLM regions, allowing discrimination of CRLM from regions of normal liver tissue eliciting unusual low AF intensity, preventing misclassification. Proof-of-concept experiments using small pieces of CRLM samples covered by large normal liver tissue demonstrated the feasibility of a dual-modality AF-Raman for detection of positive margins within few minutes. CONCLUSIONS: AF imaging and Raman spectroscopy can discriminate CRLM from normal liver tissue in an ex vivo setting. These results suggest the potential for developing integrated multimodal AF-Raman imaging techniques for intraoperative assessment of surgical margins.

Prehabilitation: high-quality evidence is still required.

Prehabilitation comprises multidisciplinary healthcare interventions, including exercise, nutritional optimisation, and psychological preparation, which aim to dampen the metabolic response to surgery, shorten the period of recovery, reduce complications, and improve the quality of recovery and quality of life. This editorial evaluates the potential benefits and limitations of and barriers to prehabilitation in surgical patients. The results of several randomised clinical trials and meta-analyses on prehabilitation show differing results, and the strength of the evidence is relatively weak. Heterogeneity in patient populations, interventions, and outcome measures, with a wide range for compliance, contribute to this variation. Evidence could be strengthened by the conduct of large-scale, appropriately powered multicentre trials that have unequivocal clinically relevant and patient-centric endpoints. Studies on prehabilitation should concentrate on recruiting patients who are frail and at high risk. Interventions should be multimodal and exercise regimens should be tailored to each patient's ability with longitudinal measurements of impact.

Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation. METHOD: A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model. RESULTS: Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76). CONCLUSION: TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.

Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis.

BACKGROUND: The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This meta-analysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition. METHODS: EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); post-pancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC). RESULTS: Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference -1.63 days (95% CI -2.80, -0.46, p = 0.006). CONCLUSIONS: EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.

Indications for staging laparoscopy in pancreatic cancer.

BACKGROUND: To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients. METHODS: Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords 'pancreatic cancer', 'resectability', 'staging', 'laparoscopy', and 'Whipple's procedure'. RESULTS: Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL. CONCLUSION: The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.

Focal nodular hyperplasia: a review of current indications for and outcomes of hepatic resection.

BACKGROUND: Focal nodular hyperplasia (FNH) is a common benign disease of the liver with no recognized potential for malignant transformation. The term describes an entity of lobular proliferation of normally differentiated hepatocytes, frequently around a central fibrous scar. Two key issues influence surgical decision making in FNH: diagnostic certainty, and symptomatic assessment. METHODS: A systematic review of studies reporting hepatic resections of FNH was performed. Indications and outcomes in adult populations were examined with a focus on diagnostic workup, patient selection and operative mortality and morbidity. RESULTS: Diagnostic modalities in the majority of studies involved ultrasound and computed tomography. Fewer than half employed magnetic resonance imaging (MRI). In instances in which MRI was not available, diagnostic accuracy was inferior. CONCLUSIONS: Percutaneous biopsy should be avoided to prevent the risk for tumour seeding. Patients presenting with asymptomatic definitive FNH can be safely managed conservatively. In symptomatic patients surgical resection is a safe and effective treatment for which acceptable rates of morbidity (14%) and zero mortality are reported. However, evidence of symptom resolution is reported with conservative strategies. Diagnostic uncertainty remains the principal valid indication for FNH resection, but only in patients in whom contrast-enhanced MRI forms part of preoperative assessment.

Critical review of the prognostic significance of pathological variables in patients undergoing resection for colorectal liver metastases.

OBJECTIVE: The aim of this study was to identify prognostic factors, particularly pathological variables, that influence disease-free and overall survival following resection for colorectal liver metastases (CRLM). METHODS: Patients undergoing CRLM resection from January 2005 to December 2011 were included. Data analysed included information on demographics, laboratory results, operative findings, histopathological features and survival. RESULTS: A total of 259 patients were included. Of these, 138 (53.3%) patients developed recurrent disease, of which 95 died. The median length of follow-up in the remaining patients was 28 months (range: 12-96 months). There were significant associations between recurrence and higher tumour number (P = 0.002), presence of perineural invasion (P = 0.009) and positive margin (R1) resection (P = 0.002). Multivariate analysis showed all three prognostic factors to be independent predictors of disease-free survival. Significantly poorer overall survival after hepatic resection for CRLM was observed in patients undergoing hemi-hepatectomy or more radical resection (P = 0.021), patients with a higher number of tumours (P = 0.024) and patients with perineural invasion (P < 0.001). Multivariate analysis showed perineural invasion to be the only independent predictor of overall survival. CONCLUSIONS: The presence of perineural invasion, multiple tumours and an R1 margin were associated with recurrent disease. Perineural invasion was also an independent prognostic factor with respect to overall survival.

Management of incidental and suspicious gallbladder cancer: focus on early referral to a tertiary centre.

OBJECTIVES: This study was conducted to assess the management of incidental gallbladder cancer and indeterminate gallbladder lesions. Its secondary aim referred to the devising of a management pathway for these patients. METHODS: Patients referred with incidental gallbladder cancer and indeterminate gallbladder lesions during 2002-2011 were identified from a prospectively maintained database. Collated data included operative findings, histopathological data and survival outcomes. RESULTS: The study included a total of 104 patients, 40 of whom had incidental gallbladder cancer following cholecystectomy. In this group, the index cholecystectomy was considered curative (T-is/T1a stage) in three patients; 11 patients underwent further resection, and 26 patients were inoperable. One-, 3- and 5-year overall survival rates were 91.1%, 91.0% and 60.7%, respectively, in patients who underwent re-resection. Of the 64 patients with indeterminate gallbladder lesions, 54 patients underwent modified radical cholecystectomy. Seven patients were found to have gallbladder cancer. One-, 3- and 5-year overall survival rates were 85.9%, 43.1% and 42.8%, respectively. Five-year overall survival in patients treated with surgery for gallbladder cancer was 59.9%. CONCLUSIONS: The majority of patients with incidental gallbladder cancer were not amenable to further potentially curative resection. The radiological suspicion of gallbladder cancer should lead to prompt referral to a tertiary hepatobiliary unit for further management.

Stage IV colorectal cancer: outcomes following the liver-first approach.

BACKGROUND: To date, there is limited data on the liver-first approach in the management of colorectal liver metastases (CRLM). The aim of the study was to assess the outcomes of the liver-first approach for patients with synchronous CRLM in two tertiary referral centers. METHODS: Patients with stage IV colorectal cancer selected for the liver-first approach from January 2009 to December 2012 in two tertiary referral centers were included. Data collated included demographics, chemotherapy, operative findings, histo-pathological features, and survival. RESULTS: Thirty-seven patients with synchronous CRLM were considered for the liver-first approach. Twenty-five patients had rectal cancer. All patients underwent induction chemotherapy. Thirty patients underwent hepatic resections with no post-operative deaths. Following liver resection, five patients failed to proceed to colorectal resection and one patient had complete response to chemo-radiotherapy. Of the 25 patients that completed the liver-first approach, 13 patients had recurrent disease, of which 12 patients died. The overall 1- and 3-year survival rates were 65.9% and 30.4%, respectively. CONCLUSION: The liver-first approach is a feasible strategy for patients with synchronous CRLM and may improve survival in selected patients. The selection of patients should be incorporated in a multidisciplinary approach to achieve the best possible outcomes.

The radiological management of pseudoaneurysms complicating pancreatitis.

CONTEXT: Pseudoaneurysms associated with pancreatitis are rare, and bleeding pseudoaneurysms are associated with a high mortality. OBJECTIVE: The aim of this study was to report the outcomes of endovascular and percutaneous therapy in the management of pseudoaneurysms secondary to pancreatitis. PATIENTS: Patients who underwent angiography for pseudoaneurysms associated with pancreatitis from 2005 to 2011 were identified from the angiography database. MAIN OUTCOME MEASURES: Patient demographics, clinical presentation, radiological findings, treatment, and outcomes were retrospectively reviewed. RESULTS: Nineteen pseudoaneurysms associated with pancreatitis in 13 patients were identified. The diagnosis of a pseudoaneurysm was made by computerised tomography angiography in seven patients, followed by portal venous phase contrast enhanced CT (n=4), duplex ultrasound (n=1) and angiography (n=1). At angiography, coil embolisation was attempted in 11 patients with an initial success rate of 82% (n=9). One patient underwent successful embolisation with percutaneous thrombin injection. The recurrence rate following initial successful embolisation was 11% (n=1). There were no episodes of re-bleeding following embolisation but re-bleeding following thrombin injection was observed in one case. The morbidity and mortality rate in the 12 patients that were successfully treated was 25% (n=3) and 8% (n=1), respectively. All 12 patients that were successfully treated demonstrated radiological resolution of their pseudoaneurysms, with a median follow-up of 20 months. CONCLUSION: Endovascular embolisation is a suitable first-line management strategy associated with low recurrence rates. The role of percutaneous thrombin injection is yet to be defined.

Outcomes in patients with indeterminate pulmonary nodules undergoing resection for colorectal liver metastases.

OBJECTIVES: This study aimed to assess outcomes in patients who underwent hepatic resection for colorectal liver metastases (CRLM) with subcentimetre indeterminate pulmonary nodules (IPN) and to devise a management pathway for these patients. METHODS: Patients undergoing CRLM resection from January 2006 to December 2010 were included. Survival differences following liver resection in patients with and without IPN were determined. RESULTS: A total of 184 patients were included, 30 of whom had IPN. There were no significant differences between the IPN and non-IPN groups in terms of demographics, surgery and pathological factors. There were no significant differences between patients with and without IPN with respect to disease-free (P= 0.190) and overall (P= 0.710) survival. Fifteen patients with IPN progressed to metastatic lung disease over a median period of 10 months (range: 3-18 months); six of these patients underwent lung resection. Of the remaining 15 patients with IPN, eight showed no IPN progression and subsequent CT scans did not identify IPN in the remaining seven. CONCLUSIONS: Colorectal liver metastases patients with IPN who have resectable disease should be treated with liver resection and should be subject to intensive surveillance post-resection. Although 50% of these patients will progress to develop lung metastases, this does not appear to influence survival following liver resection.

A Multicenter, Randomized, Double-Blinded, Clinical Trial Comparing Cattell-Warren and Blumgart Anastomoses Following Partial Pancreatoduodenectomy: PANasta Trial.

Whether a Blumgart anastomosis (BA) is superior to Cattell-Warren anastomosis (CWA) in terms of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy. Importance: Complications driven by POPF following pancreatic cancer resection may hinder adjuvant therapy, shortening survival. BA may reduce complications compared to CWA, improving the use of adjuvant therapy and prolonging survival. Methods: A multicenter double-blind, controlled trial of patients undergoing resection for suspected pancreatic head cancer, randomized during surgery to a BA or CWA, stratified by pancreatic consistency and duct diameter. The primary end point was POPF, and secondary outcome measures were adjuvant therapy use, specified surgical complications, quality of life, and survival from the date of randomization. For a 10% POPF reduction, 416 patients were required, 208 per arm (two-sided α = 0·05; power = 80%). Results: Z-score at planned interim analysis was 0.474 so recruitment was held to 238 patients; 236 patients were analyzed (112 BA and 124 CWA). No significant differences in POPF were observed between BA and CWA, odds ratio (95% confidence interval [CI]) 1·04 (0.58-1.88), P = 0.887, nor in serious adverse events. Adjuvant therapy was delivered to 98 (62%) of 159 eligible patients with any malignancy; statistically unrelated to arm or postoperative complications. Twelve-month overall survival, hazard ratio (95% CI), did not differ between anastomoses; BA 0.787 (0.713-0.868) and CWA 0.854 (0.792-0.921), P = 0.266, nor for the 58 patients with complications, median (IQR), 0.83 (0.74-0.91) compared to 101 patients without complications 0.82 (0.76-0.89) (P = 0.977). Conclusions: PANasta represents the most robust analysis of BA versus CWA to date.

Effect of Combining EGFR Tyrosine Kinase Inhibitors and Cytotoxic Agents on Cholangiocarcinoma Cells.

PURPOSE: The potential of members of the epidermal growth factor receptor (ErbB) family as drug targets in cholangiocarcinoma (CCA) has not been extensively addressed. Although phase III clinical trials showed no survival benefits of erlotinib in patients with advanced CCA, the outcome of the standard-of-care chemotherapy treatment for CCA, gemcitabine/cisplatin, is discouraging so we determined the effect of other ErbB receptor inhibitors alone or in conjunction with chemotherapy in CCA cells. MATERIALS AND METHODS: ErbB receptor expression was determined in CCA patient tissues by immunohistochemistry and digital-droplet polymerase chain reaction, and in primary cells and cell lines by immunoblot. Effects on cell viability and cell cycle distribution of combination therapy using ErbB inhibitors with chemotherapeutic drugs was carried out in CCA cell lines. 3D culture of primary CCA cells was then adopted to evaluate the drug effect in a setting that more closely resembles in vivo cell environments. RESULTS: CCA tumors showed higher expression of all ErbB receptors compared with resection margins. Primary and CCA cell lines had variable expression of erbB receptors. CCA cell lines showed decreased cell viability when treated with chemotherapeutic drugs (gemcitabine and 5-fluorouracil) but also with ErbB inhibitors, particularly afatinib, and with a combination. Sequential treatment of gemcitabine with afatinib was particularly effective. Co-culture of CCA primary cells with cancer-associated fibroblasts decreased sensitivity to chemotherapies, but sensitized to afatinib. CONCLUSION: Afatinib is a potential epidermal growth factor receptor targeted drug for CCA treatment and sequential treatment schedule of gemcitabine and afatinib could be explored in CCA patients.

Prognostic scores for colorectal liver metastasis: clinically important or an academic exercise?

OBJECTIVES: Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability. METHODS: Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords 'colorectal cancer', 'metastases', 'liver resection' and 'hepatectomy'. RESULTS: Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81-1568 patients) and median follow-up was 35 months (range 16-52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis. CONCLUSIONS: There is no 'ideal' prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.

Adherence to Antibiotic Prophylaxis for Percutaneous Transhepatic Cholangiography: A Single-Centre Experience.

Background Percutaneous transhepatic cholangiography (PTC) is associated with high rates of sepsis. The aim of the current study was to audit the adherence to trust guidelines on antibiotic prophylaxis in patients undergoing PTC. Secondary aims included the management and outcome of patients with sepsis post-procedure. Methods This was a retrospective analysis of 50 consecutive patients who underwent a PTC procedure between January 2016 to January 2017. Collated data included PTC indication, drug allergies, antibiotics given pre-PTC, culture results, and antibiotic sensitivities within one-month post-PTC. Results Complete data were available for 41 patients and 61 PTC procedures. The median age was 68 years, and 51% were females. The indication for PTC was malignancy (n=32, 78%), benign conditions (n=1, 2%), and unknown diagnosis at the time of PTC (n=8, 20%). Three cases did not receive antibiotic prophylaxis. Only 27 (44%) PTC procedures received appropriate pre-PTC antibiotics as per guidelines, with no adherence to guidelines in all penicillin-allergic patients. In six patients who were not being treated for sepsis pre-PTC, a newly positive post-PTC blood/drain culture was observed within one month. Organisms grown in the post-PTC cultures were 56% gram-negative, the majority being Escherichia coli. The 30-day mortality rate was 12.2% (5/41). Conclusions Poor adherence to recommended antibiotic regimes is a significant contributing factor for sepsis post-PTC. Investigating barriers to guideline implementation, stricter adherence, and peer education are interventions that could improve post-PTC outcomes.

C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy.

Purpose The objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy. Methods Patients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed.  Results A total of 149 patients were included. Cholecystitis was the most common diagnosis (n = 86, 57.7%), followed by acute pancreatitis (n = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as "difficult". The overall morbidity rate was 15.4% (n = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years (p = 0.012), underlying diagnosis (p = 0.010), presence of heart rate >90 (p = 0.027), and an elevated pre-surgery CRP >100 (p < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy (p = 0.041). Conclusions An elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting.

Surgical technique and systemic inflammation influences long-term disease-free survival following hepatic resection for colorectal metastasis.

BACKGROUND: To date, there is limited data available on prognostic factors that influence long-term disease-free survival following hepatic resection for colorectal liver metastasis (CRLM). The aim of the study was to identify prognostic factors that were associated with long-term disease-free survival (>5 years) following resection for CRLM. METHODS: Patients undergoing resection for CRLM from January 1993 to March 2007 were identified from the hepatobiliary database. Data analyzed included demographics, laboratory results, operative findings and histopathological data. RESULTS: Seven hundred five curative primary hepatic resections were performed, of which 434 patients developed disease recurrence within 5 years and 67 patients were disease-free more than 5 years. There was a significant association between systemic inflammatory response (raised neutrophil to lymphocyte ratio and/or C-reactive protein), blood transfusion, >2 tumors, bilobar disease and resection margin involvement with developing recurrence during the follow-up period. On multivariate analysis, three independent predictors for recurrent disease within the 5-year follow-up were identified: pre-operative inflammatory response; blood transfusion requirement; and status of resection margin. CONCLUSION: Absence of a systemic inflammatory response and surgical technique to minimize transfusion requirements and obtain a R0 resection margin, are associated with long-term disease-free survival.

Papillary adenoma of the distal common bile duct associated with a synchronous carcinoma of the peri-ampullary duodenum.

CONTEXT: Benign tumours of the biliary tract are an extremely rare group of neoplasms. The diagnosis of these rare tumours is established on histopathological analysis following resection. Coincidence of a biliary adenoma of the distal common bile duct and a synchronous adenocarcinoma of the peri-ampullary duodenum has never been reported in the literature. CASE REPORT: We report a case of a papillary adenoma in the common bile duct in a 75-year-old female, who had synchronous invasive adenocarcinoma of the peri-ampullary duodenum. CONCLUSION: Isolated papillary adenoma of the bile duct is extremely rare, and in this unusual case it coincided with a peri-ampullary duodenal adenocarcinoma. However, this is a rare instance of an incidental finding within the distal bile duct following pancreaticoduodenectomy for curative treatment of a peri-ampullary adenocarcinoma.

Results following surgical resection for malignant pancreatic neuroendocrine tumours. A single institutional experience.

OBJECTIVE: The aim of the study was to present clinical outcomes of patients with malignant pancreatic neuroendocrine tumours (NET) following surgical resection with curative intent. Clinical and pathological factors that influenced the outcomes were also analysed. DESIGN: Retrospective case note study. PATIENTS: All patients with pancreatic NET that underwent surgery over a 7-year period (1999-2006). RESULTS: Twelve patients were identified with a median age at diagnosis of 54 years (range: 24-79 years). Common presenting symptoms include abdominal pain (n=8) and weight loss (n=3). Overall morbidity was 25% with one post-operative death. The median follow-up period was 41 months (range: 9-156 months). The overall 2- and 5-year actuarial survival rates were 88% and 70%, respectively. The overall survival was better in patients treated with surgery compared to patients managed medically (P<0.001). The disease-free survival rates were 62% at 2 and 5 years, respectively. Recurrent disease occurred in four patients and the median disease-free interval was 6 months (range: 3-14 months). On univariate analysis, angio-invasion (P=0.015) and degree of differentiation (P=0.024) were associated with developing recurrent disease. CONCLUSION: Surgical resection of malignant pancreatic NET results in good long-term survival in selected patients.

Carcinoma of the body of pancreas in evolution: an aggressive disease affecting younger patients?

CONTEXT: Pancreatic body carcinoma has a poor prognosis with advanced disease at presentation. Recent experience at multidisciplinary team (MDT) meetings suggests increasing prevalence. OBJECTIVE: Our aim was to determine if introduction of MDT meetings has affected the natural history of this disease. DESIGN: Retrospective diagnostic and survival data were collected from 1995 to 2006 at two large teaching hospitals, and divided into pre- and post 2003 groups (based on MDT introduction). PARTICIPANTS: Thirty-one patients with pancreatic body carcinoma (median age at diagnosis 72 years; range 43-87 years). RESULTS: Commonest symptoms at presentation were abdominal pain and weight loss. Eight patients (25.8%) were diagnosed pre MDT (median age 71.5 years, range: 60-87 years) and 23 patients (74.2%) were diagnosed post MDT (median age 67 years, range: 43-85 years; P=0.299 vs. pre MDT). There was a significantly (P=0.024) greater prevalence of more advanced tumours post MDT (stage IV: 15/23, 65.2%) than pre MDT (stage IV: 2/8, 25.0%). Neither tumour markers nor liver biochemistry differentiated tumour stage. Best supportive care was offered to 16 patients (51.6%) while 12 patients (38.7%) were suitable for chemotherapy: 2 out of 8 pre MDT (25.0%) and 10 out of 23 (43.5%) post MDT (P=0.433). For stage III tumours, post MDT patients tended to be younger (median 59 years vs. 74.5 years, P=0.042). Survival was not significantly increased after MDT introduction but chemotherapy offered significant survival benefit on multivariate analysis (P=0.042; hazard ratio: 0.39, 95% CI: 0.16-0.97). CONCLUSION: The trend is towards increased prevalence of pancreatic body cancer and more advanced disease at presentation. Chemotherapy was associated with a survival benefit, although the introduction of the MDT has not significantly altered disease management.