Propensity score-matched outcomes analysis of the liver-first approach for synchronous colorectal liver metastases.

BACKGROUND: Liver resection before primary cancer resection is a novel strategy advocated for selected patients with synchronous colorectal liver metastases (sCRLM). This study measured outcomes in patients with sCRLM following a liver-first or classical approach, and used a validated propensity score. METHODS: Clinical, pathological and follow-up data were collected prospectively from consecutive patients undergoing hepatic resection for sCRLM at a single centre (2004-2014). Cumulative disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) were calculated by means of Kaplan-Meier analysis. Survival differences were analysed in the whole cohort and in subgroups matched according to Basingstoke Predictive Index (BPI). RESULTS: Of 582 patients, 98 had a liver-first and 467 a classical approach to treatment; 17 patients undergoing simultaneous bowel and liver resection were excluded. The median (i.q.r.) BPI was significantly higher in the liver-first compared with the classical group: 8·5 (5-10) versus 8 (4-9) (P = 0·030). Median follow-up was 34 months. The 5-year DFS rate was lower in the liver-first group than in the classical group (23 versus 45·6 per cent; P = 0·001), but there was no difference in 5-year CSS (51 versus 53·8 per cent; P = 0·379) or OS (44 versus 49·6 per cent; P = 0·305). After matching for preoperative BPI, there was no difference in 5-year DFS (37 versus 41·2 per cent for liver-first versus classical approach; P = 0·083), CSS (51 versus 53·2 per cent; P = 0·616) or OS (47 versus 49·1 per cent; P = 0·846) rates. CONCLUSION: Patients with sCRLM selected for a liver-first approach had more oncologically advanced disease and a poorer prognosis. They had inferior cumulative DFS than those undergoing a classical approach, a difference negated by matching preoperative BPI.

Close collaboration between local and specialist multidisciplinary teams allows 'fast-tracking' of patients with colorectal liver metastases.

AIM: The ongoing evolution of treatment strategies for colorectal liver metastases necessarily requires all patients to be reviewed at some point by the specialist hepatobiliary unit. This process can be streamlined through close collaboration with the local colorectal multidisciplinary team (MDT). The study was performed to see if a local colorectal MDT was able to make a correct decision regarding potential operability of liver metastases, by comparing its decision with that of two hepatobiliary surgeons in our referral centre. METHOD: CT scans of 38 patients found to have liver metastases from colorectal cancer were anonymized and sent to two hepatobiliary surgeons in our cancer network. They classified them into three categories: R, resectable; C, chemotherapy to downsize then consider resection; U, unresectable. The results were then compared with the opinion of our colorectal MDT, made before the referral to the hepatobiliary surgeons. RESULTS: The two independent hepatobiliary surgeons agreed with each other on 35/38 (92%) of CT scans. Our colorectal MDT agreed with the hepatobiliary surgeons in 36/38 (95%) of cases. Only 9 (32%) of the 28 patients deemed suitable on the CT scan by the hepatobiliary surgeons actually had a liver resection. CONCLUSION: The results show that a local colorectal MDT is able to make an accurate assessment of the operability of liver metastases. Patients deemed to be inoperable by the colorectal MDT could be 'fast-tracked' to the hepatobiliary MDT with review of imaging only, saving time and resources by avoiding referral of patients who are not suitable for liver resection.

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy.

INTRODUCTION: Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN). METHODS: Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male. RESULTS: The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%). CONCLUSIONS: Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.

The performance of master surgeons on standard aptitude testing.

BACKGROUND: Identification of the desired psychomotor abilities of optimal surgical performance, if possible, would be useful in the selection of surgical trainees. The aim of this study was to determine the level of these abilities among endoscopic consultant surgeons held in high regard by their peers. METHODS: Twenty endoscopic consultant "master" surgeons were tested on three aptitude tests: the Gibson Spiral Maze Test (error score measures eye-hand coordination), the Crawford Small Parts Dexterity Test (execution time indicates manual dexterity), and the Space Relations Test (correct scores reflect visuo-spatial ability). Their performance was compared with that of 20 medical students and the reference norm as provided by the tests' manuals. RESULTS: The median scores of master surgeons fell in the 20th, 24th, and 30th percentiles, whereas the scores of medical students fell in the 50th, 20th, and 65th percentile of norm reference for the Gibson Spiral Maze, Crawford Small Parts Dexterity, and Space Relations tests, respectively. The master surgeons enacted significantly fewer errors (Gibson Spiral Maze), had similar execution times (Crawford Small Parts Dexterity), and lower visuo-spatial scores (Space Relations) than medical students. CONCLUSION: The level of eye-hand coordination and manual dexterity of master surgeons was found to be higher than that of the average norm including medical students, while their visuo-spatial ability was lower.

Real-time thermography during energized vessel sealing and dissection.

BACKGROUND: Energized dissection systems facilitate laparoscopic dissection and hemostasis and reduce instrument traffic. However, they can introduce undesirable thermal collateral/proximity damage to adjacent structures mainly by heat conduction, although other mechanisms may be involved. The latest generation devices have the potential to reduce the incidence of such problems through use of active feedback control over the power output. This effectively regulates the delivery of energy to the target tissue with minimal thermal collateral damage. In addition, innovative heat-sink engineering of the device head ensures that the surface of the instrument tip remains cool (<45 degrees C). In this study, we evaluated the performance of this technology (LigaSure) by using dynamic infrared thermography. The thermal imaging measurements were then correlated with histopathologic studies. The overall value of in situ thermography as an adjunct to energized surgical dissection systems was also assessed. METHODS: Eight anesthetized pigs underwent open surgery to mobilize eight target vessels/organs in a randomized fashion. The LigaSure vessel sealing system with Instant Response Technology was used with three different interchangeable heads. In situ dynamic thermography was undertaken with a thermal imaging camera operating in the mid-infrared (3-5 microm) waveband and with each fully digitized 12-bit thermographic frame acquired at a rate of 60 Hz. Following sacrifice at the end of the dissection, tissue from the dissected regions was harvested for histology by an independent pathologist who was blinded to the thermographic data. RESULTS: Seals made with both the LS1000 5-mm laparoscopic head (predominantly to the small bowel and colon) and the LS1100 10-mm (Atlas) device (on the liver and short gastric tissues) were outwardly satisfactory. The average thermal spread [see text] with the LS1000 was = [see text] 4.4 mm, and the exposed surface of the instrument tip developed a temperature of approximately 100 degrees C. This instrument thus has the potential, albeit small, for heat-related proximity iatrogenic injury. The more technologically advanced LS1100 10-mm laparoscopic instrument exhibited a superior performance, with [see text] = 1.8 mm, and with a maximal temperature on the exposed surface of the jaws well within tolerable limits (approximately 35 degrees C) for use during surgery (laparoscopic or open). This was confirmed by histological studies that demonstrated negligible evidence of thermal damage. CONCLUSIONS: In situ thermal imaging represents a powerful modality for the monitoring of energized dissection/coagulation during surgery. The LigaSure system used with the LS1100 head constitutes a very safe option for energized dissection and hemostasis of vessels with a diameter of up to approximately 7 mm.

Hepatic function and non-invasive hepatosplanchnic monitoring in patients with abdominal hypertension.

A better understanding of intra-abdominal hypertension with relation to the liver is vital to the management of all forms of liver pathophysiology. Supporting good hepatic function within the critically ill patient is important not only in maintaining synthetic function, but also in avoiding the multi-organ complications of liver dysfunction. The resulting reduction in hepato-splanchnic blood flow (HSBF) observed with increasing intra-abdominal pressure has been clearly documented and seen to be exaggerated in animals with established liver disease. Unfortunately the tools required to measure this, remain difficult to apply routinely in the clinical setting and as such goal directed therapy to specifically improve the hepatosplanchnic circulation remains elusive. Given the documented effects of lAP on HSBF and the relatively high incidence of intra-abdominal hypertension and the abdominal compartment syndrome within "liver patients" as a whole, close attention to IAP and timely correction by appropriate medical or surgical means would appear to be essential.

Hepatic function and non-invasive hepatosplanchnic monitoring in patients with abdominal hypertension.

A better understanding of intra-abdominal hypertension with relation to the liver is vital to the management of all forms of liver pathophysiology. Supporting good hepatic function within the critically ill patient is important not only in maintaining synthetic function, but also in avoiding the multi-organ complications of liver dysfunction. The resulting reduction in hepato-splanchnic blood flow (HSBF) observed with increasing intra-abdominal pressure has been clearly documented and seen to be exaggerated in animals with established liver disease. Unfortunately the tools required to measure this, remain difficult to apply routinely in the clinical setting and as such goal directed therapy to specifically improve the hepatosplanchnic circulation remains elusive. Given the documented effects of IAP on HSBF and the relatively high incidence of intra-abdominal hypertension and the abdominal compartment syndrome within "liver patients" as a whole, close attention to IAP and timely correction by appropriate medical or surgical means would appear to be essential.

Digestive tract schwannoma.

BACKGROUND: Digestive tract schwannomas (DTS) are rare benign mesenchymal tumours usually affecting females between 30 and 60 years old. METHODS: We retrospectively reviewed 2 cases of DTS treated at our hospital. The first case is a 38-year-old female with gastric schwannoma presenting with acute upper gastro-intestinal bleeding. The second case is a 36-year-old female with mesenteric schwannoma presenting with chronic right iliac fossa pain. Both patients underwent surgical resection of the tumour. RESULTS: Histology and immunohistochemistry revealed the typical appearance of a DTS. CONCLUSION: DTS is most commonly found in the stomach. It is usually asymptomatic but can present with variable symptoms. Definitive diagnosis can only be made on the basis of immunohistochemistry. Surgical resection is the treatment of choice.

Methods for improving performance under reverse alignment conditions during endoscopic surgery.

BACKGROUND: There are times during endoscopic procedures when the surgeon has to operate ahead of the camera/telescope assembly. As a result, the image displayed on the monitor will be an inverted mirror image of the operative field (reverse alignment). The present study addresses the extent of these difficulties and suggests some techniques that may be used to overcome the problem. METHODS: Eight specialist registrars participated in experiments involving the execution of a simulated dissection task under 12 different imaging conditions. These conditions included normal alignment, reverse alignment, total or partial digital correction of reverse alignment (about the horizontal and vertical axes independently and together), and a simple rotation of the camera through 180 degrees. Normal, reverse, and corrected reverse alignment were also tested with optical axes of 45 degrees and 60 degrees. The endpoints were the task execution and the errors rate. RESULTS: A marked deterioration in execution time was observed when the surgeons worked under reverse alignment rather than under normal viewing (p = 0.036). Significant improvement in execution-time errors rate was found when both the horizontal and vertical axes were digitally corrected simultaneously (p = 0.27) and when the camera was rotated 180 degrees with respect to the telescope during reverse alignment (p = 0.28). CONCLUSIONS: The effect on performance produced by reverse alignment of the endoscope and instruments can be overcome by means of digital electronic processing, or simply by turning the camera through 180 degrees.