Increased multimodality treatment options has improved survival for Hepatocellular carcinoma but poor survival for biliary tract cancers remains unchanged.

BACKGROUND: Primary hepatobiliary cancer incidence in the UK is rising and survival rates are low. Surgery is the main curative option for these cancers, but multimodality therapies are expanding. The aim of our original study was to determine trends in survival, over an 8-year period, of patients treated for primary hepatobiliary cancers at our tertiary referral Centre. METHOD: Patients treated for the most common types of primary hepatobiliary cancers, namely Hepatocellular carcinoma (HCC), Cholangiocarcinoma and Gallbladder cancer between January 2009 and December 2016 were retrospectively analysed from a prospective database linked to UK Hospital Episode Statistics data. RESULTS: A total of 1536 patients with primary hepatobiliary cancers were assessed and treatment plans formulated at our supra-regional specialist Hepatobiliary MDT. The primary hepatobiliary cancers treated were HCC (n = 836), Cholangiocarcinoma (n = 516), and Gallbladder cancer (n = 184). Survival for all the 3 cancers was significantly better with curative treatment. Overall median survival times were 350, 180, and 150 days respectively for HCC, Cholangiocarcinoma and Gallbladder cancer. Excluding best supportive care patients, the respective survival figures were 900, 600, and 400 days. Survival for HCC patients improved over time and was significantly increased in the final 3 years of the study (p ≤ 0.011 for all). Cholangiocarcinoma and Gallbladder cancer survivals were poor and did not change significantly over time. CONCLUSION: HCC outcome has improved in association with expanded multimodal therapies. Survivals for cholangiocarcinoma and gallbladder cancer remain poor in parallel with limited expansion of multimodal therapies highlighting an unmet therapeutic need for biliary tract cancers.

Objective assessment of trainee operative experience in a tertiary hepatobiliary unit.

INTRODUCTION: Indicative numbers for completion of training (CCT) in the UK requires 35 upper Gastrointestinal/Hepatobiliary resections and 110 (50 non HPB trainees) cholecystectomies. We aim to identify whether the training experience in our centre meets the CCT requirements for hepatobiliary surgery and compare training opportunities to those in international fellowships. METHODS: We retrospectively reviewed our hospital's operating theatre database for all patients undergoing a liver or gallbladder resection between January 2008 and July 2015 using corresponding procedural codes and consultant name. The cohort was categorized based on case and primary operating surgeon. The training grade of the surgeon was split into junior registrar (ST3/5), senior registrar (ST6/8) and senior fellow (post-CCT). RESULTS: Over a 7.5 year period we performed 2301 hepatobiliary procedures. The senior fellows and senior registrars performed a median of 42 liver resections (range 15-94) and 77 (range 35-110) cholecystectomies as the primary operator in any given 12 month period. The academic output for the unit was 104 over this period, with a median publication rate of 1.34 papers/trainee in any given 12 months. 15/16 senior fellow/senior registrars went on to secure substantive hepatobiliary consultant posts. CONCLUSIONS: Our centre delivers in excess of the required operative volume and clinical competencies for CCT in Hepatobiliary surgery in a 12 month period and exposure of trainees to operative experience is commensurate to the best performing international fellowships.

The role of ultrasound in the management of patients with occult groin hernias.

INTRODUCTION: Groin ultrasound scanning is commonly used to examine patients with obscure groin pain or swelling. A recent study has shown ultrasound has a poor positive predictive value (PPV) in diagnosing groin hernias although earlier studies reported PPV values as high as 100%. Our aims were to calculate ultrasound's accuracy in diagnosing occult groin hernias in symptomatic patients and assess how management of these patients is affected by ultrasound result. METHODS: We retrospectively analysed 375 symptomatic adult patients, who between February 2008 and March 2010, had ultrasound to diagnose groin hernias when clinical examination was inconclusive. Patients were identified on a prospective radiology database and all groin ultrasounds were performed by either one consultant radiologist or one radiographer. RESULTS: Ultrasound was positive in 199 patients, of which 118 underwent surgery. Using operative findings as the gold standard, ultrasound's PPV for groin hernias was 70% (95% CI: 62-78%). Ultrasound was equivocal in 42 patients of which hernias were diagnosed in 7 of the 10 who had surgery. Ultrasound was negative in 151 patients of which none were later diagnosed with hernias during 3 years' median follow-up. CONCLUSION: Ultrasound is poor in diagnosing occult groin hernias with a PPV of 70% suggesting a 30% chance of negative groin exploration. The equivocal ultrasound group requires careful follow-up as a considerable number were later diagnosed with hernia. The absence of subsequent hernia diagnosis in the negative ultrasound group suggests it may be a useful rule-out test to exclude occult groin hernias in symptomatic patients.

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.