Telephone assessment of new hernia referrals-is it possible?

PURPOSE: Utilisation of remote clinics is increasing in healthcare settings worldwide. During the height of the COVID pandemic, our UK-based teaching hospital has trialled telephone assessment for new patients presenting with primary hernias. Selected cases are listed for elective repair of primary hernia direct from telephone clinic assessment. In March 2021, after this process had been in place for 13 months, departmental triage criteria were introduced, allocating patients to initial assessment in Face to Face or Telephone Clinics. Here, we evaluate the effectiveness of telephone assessment, with specific attention to 'Day of Surgery' cancellation. We also assess the effect of our triage criteria on rate of 'Day of Surgery' cancellation. METHODS: Departmental diaries were studied retrospectively to identify patients listed for hernia repair between February 2020 and February 2022. Data were obtained from clinic letters, discharge paperwork and operating lists, as well as from management teams. Fishers Exact test was used to compare groups seen either face to face or remotely as well and pre- and post-intervention. RESULTS: 325 patients were listed for hernia repair, 56 after telephone assessment. 6 (11%) of those listed from telephone clinic were cancelled on the day of surgery, compared with 34 (13%) of those seen face to face. With triage criteria in place, listing from telephone clinic increased significantly from 14 to 27%. Overall day of surgery cancellations reduced from 13 to 9%. Rate of day of surgery cancellation in those assessed in telephone clinic reduced from 12 to 9%. CONCLUSIONS: There is no significant difference between day of surgery cancellations after face to face or telephone clinic assessment. Triage criteria for telephone assessment appear to increase the numbers being listed after remote clinics. This did not significantly impact the number of day of surgery cancellations.

A Foley catheter 'the jack of all trades': a literature review of its common and novel uses.

The Foley catheter is one of the most commonly used devices in modern surgical practice. Developed for draining the urinary bladder, this humble catheter has been employed for many other purposes ranging from urine output monitoring to complex urological investigations. Over time, it has evolved into being applied in more complex and innovative ways in various other specialties apart from urology. In this review article, we describe some of the common and novel uses of this deceptively simple device, and discuss the scope of its application in modern medicine.

Impact of digital technologies on self-efficacy in people with Parkinson's: a scoping review protocol.

INTRODUCTION: Parkinson's disease (PD) is the second most common neurological disease globally, for which currently no one definitive cause or cure exists. Estimates suggest that 145 000 people with Parkinson's (PwP) live in the UK. PD presents with motor and non-motor symptoms fluctuating significantly in and between individuals continually throughout the day. PD adversely affects activities of daily living, quality of life and well-being. Self-efficacy is an important belief to improve for PwP as it enables the individual to develop confidence in their ability to exert control over their own motivation, behaviour and social environment. This scoping review aims to identify digital technologies which have been shown to positively impact on promoting self-efficacy in PwP. METHODS AND ANALYSES: Six bibliographic databases MEDLINE, PsycINFO, Web of Science, CINAHL, EMBASE and IEEE Xplore will be searched from the date of their inception to the May 2023. The primary outcome will be to identify interventions which are associated with a change in self-efficacy in PwP to enable positive and negative outcomes, as well as safety to be evaluated. The secondary outcomes of this review will focus on the intervention's proposed mechanisms for success, particularly looking at the impact they had on positive behaviour change(s) or modification(s) on study participants. ETHICS AND DISSEMINATION: This scoping review will not require ethical approval as it will use data collected from previously published primary studies. The findings of this review will be published in peer-reviewed journals and widely disseminated.

Safety profile and outcomes of intraoperative ultrasound-guided remnant cholecystectomy.

INTRODUCTION: Subtotal cholecystectomy (STC) is a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study evaluates the safety profile and perioperative outcomes of remnant cholecystectomy (RC) performed under intraoperative ultrasound guidance. METHODS: We retrospectively reviewed the records of all patients that underwent RC under intraoperative ultrasound guidance in 2009 and 2019. Pre-, intra- and postoperative details of patients who underwent RC were obtained from patients' electronic and paper copy records. RESULTS: Ninety-seven patients underwent STC during the study period. Of this cohort, 16 patients (16.5%) presented with symptomatic gallbladder remnant over a median follow-up period of 14 months (interquartile range [IQR] 2-26). The median age was 64 years (IQR 54-69) with an equal male-to-female distribution. The median body mass index was 31kg/m2 (IQR 28-33). Twelve of 16 patients (75%) then proceeded to elective RC. Intraoperative ultrasound was used in all cases to identify the location of the remnant gallbladder and biliary anatomy. The median operative time was 88min (IQR 80-96), with 67% completed laparoscopically. No patients suffered bile duct injury. The median hospital stay was 3 days (IQR 1-5). During the follow-up period, eight patients (67%) reported symptom resolution. CONCLUSIONS: RC is a safe operation that can be performed laparoscopically even after previous open subtotal cholecystectomy. We recommend the routine use of intraoperative ultrasound as an adjunct for identifying remnant gallbladder and biliary anatomy in all patients.

The impact of myosteatosis on outcomes following surgery for gastrointestinal malignancy: a meta-analysis.

INTRODUCTION: The aim of this review was to evaluate the impact of preoperative myosteatosis on long-term outcomes following surgery for gastrointestinal malignancy. METHODS: We conducted a systematic search of the electronic information sources, including PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and AMED. Studies were included if they reported the impact of preoperatively defined myosteatosis, or a similar term, on long-term survival outcomes following surgery for gastrointestinal malignancy. A subgroup analysis was performed for those studies reporting outcomes for colorectal cancer patients only. FINDINGS: Thirty-nine full-text articles were reviewed for inclusion, with 19 being retained after the inclusion criteria were applied. The total number of included patients across all studies was 14,481. Patients with myosteatosis had significantly poorer overall survival, according to univariate (hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.67-1.99) and multivariable (HR 1.66, 95% CI 1.49-1.86) analysis. This was also demonstrated for cancer-specific survival (univariate HR 1.62, 95% CI 1.18-2.22; multivariable HR 1.73, 95% CI 1.48-2.03) and recurrence-free survival (univariate HR 1.28, 95% CI 1.10-1.48; multivariable HR 1.38, 95% CI 1.07-1.77). CONCLUSIONS: This meta-analysis demonstrates that patients with preoperative myosteatosis have poorer long-term survival outcomes following surgery for gastrointestinal malignancy. Therefore, myosteatosis should be used for preoperative optimisation and as a prognostic tool before surgery. More standardised definitions of myosteatosis and further cohort studies of patients with non-colorectal malignancies are required.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION: Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC. METHODS: We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study. RESULTS: A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC. CONCLUSIONS: STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity.

BACKGROUND/AIMS: A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed. METHODS: A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality. RESULTS: Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131). CONCLUSIONS: In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.

Intention to Treat Laparoscopic Versus Open Hemi-Hepatectomy: A Paired Case-Matched Comparison Study.

BACKGROUND: The benefits of laparoscopic hemi-hepatectomy compared to open hemi-hepatectomy are not clear. OBJECTIVE: This study aims to share our experience with the laparoscopic hemi-hepatectomy compared to an open approach. METHODS: A total of 40 consecutive laparoscopically started hemi-hepatectomy (intention-to-treat analysis) cases between August 2012 and October 2015 were matched against open cases using the following criteria: laterality of surgery and pathology (essential criteria); American Society of Anesthesiologists score, body mass index, pre-operative bilirubin, neo-adjuvant chemotherapy, additional procedures, portal vein embolization, and presence of cirrhosis/fibrosis on histology (secondary criteria); age and gender (tertiary criteria). Hand-assisted and extended hemi-hepatectomy cases were excluded from the study. The two groups were compared for blood loss, operative time, hospital stay, morbidity, mortality, and oncological outcomes. All complications were quantified using the Clavien-Dindo classification. RESULTS: Two groups were well matched (p = 1.00). In the two groups, 10 patients had left and 30 had right hemi-hepatectomy. Overall conversion rate was 15%. Median length of hospital and high dependency unit stay was less in the intention to treat laparoscopic hemi-hepatectomy group: 6 versus 8 days, p = 0.025 and 1 versus 2 days, p = 0.07. Median operative time was longer in the intention to treat laparoscopic hemi-hepatectomy group: 420 min (range: 389.5-480) versus 305 min (range: 238.8-348.8; p = 0.001). Intra-operative blood loss was equivalent, but the overall blood transfusions were higher in the intention to treat laparoscopic hemi-hepatectomy (50 vs 29 units, p = 0.36). The overall morbidity (18 vs 20 patients, p = 0.65), mortality (2.5%), and the positive resection margin status were similar (18% vs 21%, p = 0.76). The 1- (87.5% vs 92.5%, p = 0.71) and 3-year survival (70% vs 72.5%, p = 1.00) was also similar. CONCLUSIONS: We observed lower hospital and high dependency unit stay in the laparoscopic group. However, the laparoscopic approach was associated with longer operating time and a non-significant increase in blood transfusion requirements. There was no difference in morbidity, mortality, re-admission rate, and oncological outcomes.

Multicentre observational cohort study of implementation and outcomes of laparoscopic distal pancreatectomy.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasingly being performed as an alternative to open surgery. Whether the implementation and corresponding learning curve of LDP have an impact on patient outcome is unknown. The aim was to investigate the temporal trends in practice across UK centres. METHODS: This was a retrospective multicentre observational cohort study of LDP in 11 tertiary referral centres in the UK between 2006 and 2016. The learning curve was analysed by pooling data for the first 15 consecutive patients who had LDP and examining trends in surgical outcomes in subsequent patients. RESULTS: In total, 570 patients underwent LDP, whereas 888 underwent open resection. For LDP the median duration of operation was 240 min, with 200 ml blood loss. The conversion rate was 12·1 per cent. Neuroendocrine tumours (26·7 per cent) and mucinous cystic neoplasms (19·7 per cent) were commonest indications. The proportion of LDPs increased from 24·4 per cent in 2006-2009 (P1) to 46·0 per cent in 2014-2016 (P3) (P < 0·001). LDP was increasingly performed for patients aged 70 years or more (16 per cent in P1 versus 34·4 per cent in P3; P = 0·002), pancreatic ductal adenocarcinoma (6 versus 19·1 per cent; P = 0·005) and advanced malignant tumours (27 versus 52 per cent; P = 0·016). With increasing experience, there was a trend for a decrease in blood transfusion rate (14·1 per cent for procedures 1-15 to 3·5 per cent for procedures 46-75; P = 0·008), ICU admissions (32·7 to 19·2 per cent; P = 0·021) and median duration of hospital stay (7 (i.q.r. 5-9) to 6 (4-7) days; P = 0·002). After 30 procedures, a decrease was noted in rates of both overall morbidity (57·7 versus 42·2 per cent for procedures 16-30 versus 46-75 respectively; P = 0·009) and severe morbidity (18·8 versus 9·7 per cent; P = 0·031). CONCLUSION: LDP has increased as a treatment option for lesions of the distal pancreas as indications for the procedure have expanded. Perioperative outcomes improved with the number of procedures performed.

ANTECEDENTES: Cada día se utiliza más la pancreatectomía distal laparoscópica (laparoscopic distal pancreatectomy, LDP) como una alternativa a la cirugía abierta. Se desconoce si la implementación y la correspondiente curva de aprendizaje de la LDP tienen impacto en los resultados. El objetivo fue investigar las tendencias relacionadas con su implementación en los centros del Reino Unido a los largo del tiempo. MÉTODOS: Se realizó el estudio observacional retrospectivo y multicéntrico de una cohorte de LDP en once centros de referencia terciarios del Reino Unido entre 2006-2016. Se analizó la curva de aprendizaje agrupando los 15 primeros pacientes consecutivos de LDP y se compararon los resultados quirúrgicos con los obtenidos en los pacientes subsiguientes. RESULTADOS: En total, se incluyeron 570 pacientes con LDP y 888 con resección abierta. Para el LDP, la mediana de tiempo operatorio fue de 240 minutos con 200 ml de pérdida de sangre. La tasa de conversión fue del 12,2%. Las indicaciones más frecuentes fueron los tumores neuroendocrinos (26,7%) y las neoplasias quísticas mucinosas (19,7%). La proporción de LDP aumentó del 24% al 46% (de 2006-2009 a 2014-2016; P < 0,001). La LDP se realizó cada vez con mayor frecuencia en pacientes de ≥ 70 años (15,8% versus 34,4%, P = 0,002), en pacientes con adenocarcinoma ductal pancreático (6,5% versus 19,1%, P = 0,005) y en pacientes con tumores malignos avanzados (27,3% versus 51,85%, P = 0,016). Con el aumento de la experiencia, disminuyeron las tendencias de la tasa de transfusión sanguínea (14,1% al 3,5%, P = 0,008), los ingresos en la UCI (32,7% a 19,2%, P = 0.021) y la mediana de la duración de la estancia hospitalaria (7 (rango intercuartílico 5-9) a 6 (rango intercuartilico 4-7) días, P = 0,002). Tras 30 procedimientos, disminuyeron tanto la morbilidad global (57,7% versus 42,2%, P = 0,009) como las tasas de morbilidad grave (21,5% versus 14,6%, P = 0,022). CONCLUSIÓN: La pancreatectomía distal laparoscópica se ha incrementado como una opción de tratamiento para las lesiones del páncreas distal a medida que se han ido ampliando las indicaciones del procedimiento. Los resultados perioperatorios mejoran con el número de procedimientos realizados.

Percutaneous Cholecystostomy for Severe Acute Cholecystitis: A Useful Procedure in High-Risk Patients for Surgery.

BACKGROUND: Acute cholecystitis has the potential to cause sepsis and death, particularly in patients with poor physiological reserve. The gold standard treatment of acute cholecystitis (cholecystectomy) is often not safe in high-risk patients and recourse is made to percutaneous cholecystostomy as either definite treatment or temporizing measure. The aim of this study is to evaluate early and late outcomes following percutaneous cholecystostomy in patients with acute cholecystitis treated at our institution. METHODS: All patients who underwent percutaneous cholecystostomy for acute cholecystitis (excluding patients with malignancy) between January 2005 and September 2014 were included in the study. RESULTS: A total of 53 patients (22 female, median age, 74 years; range, 27-95 years) underwent percutaneous cholecystostomy during the study period. In total, 12 patients (22.6%) had acalculous cholecystitis. The main indications for percutaneous cholecystostomy were significant co-morbidities (n = 28, 52.8%) and patients too unstable for surgery (n = 21, 39.6%). The median time to percutaneous cholecystostomy from diagnosis of acute cholecystitis was 3.6 days (range, 0-45 days). The median length of hospital stay was 27 (range, 4-87) days. The overall 90-day mortality was 9.3% with two further deaths at 12-month follow up. The mortality was significantly higher in patients with American Society of Anesthesiology grade 4-5 (18% vs 0% in American Society of Anesthesiology grade 2-3, p = 0.026) and in patients with acalculous cholecystitis (25% vs 4.5%, p = 0.035). The overall readmission rate was 18%. A total of 24 (45.2%) patients had surgery: laparoscopic cholecystectomy, n = 11; laparoscopic converted to open, n = 5; open total cholecystectomy, n = 5; open cholecystectomy, n = 1; laparotomy and washout, n = 1; laparotomy partial cholecystectomy and closure of perforated small intestine and gastrostomy, n = 1. CONCLUSION: Percutaneous cholecystostomy is a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery.

Comparison of risk-scoring systems in the prediction of outcome after liver resection.

BACKGROUND: Risk prediction techniques commonly used in liver surgery include the American Society of Anesthesiologists (ASA) grading, Charlson Comorbidity Index (CCI) and cardiopulmonary exercise tests (CPET). This study compares the utility of these techniques along with the number of segments resected as predictive tools in liver surgery. METHODS: A review of a unit database of patients undergoing liver resection between February 2008 and January 2015 was undertaken. Patient demographics, ASA, CCI and CPET variables were recorded along with resection size. Clavien-Dindo grade III-V complications were used as a composite outcome in analyses. Association between predictive variables and outcome was assessed by univariate and multivariate techniques. RESULTS: One hundred and seventy-two resections in 168 patients were identified. Grade III-V complications occurred after 42 (24.4%) liver resections. In univariate analysis of CPET variables, ventilatory equivalents for CO2 (VEqCO2) was associated with outcome. CCI score, but not ASA grade, was also associated with outcome. In multivariate analysis, the odds ratio of developing grade III-V complications for incremental increases in VEqCO2, CCI and number of liver segments resected were 1.09, 1.49 and 2.94, respectively. CONCLUSIONS: Of the techniques evaluated, resection size provides the simplest and most discriminating predictor of significant complications following liver surgery.

Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer.

BACKGROUND: The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS: This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS: A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION: In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

The pre-operative rate of growth of colorectal metastases in patients selected for liver resection does not influence post-operative disease-free survival.

AIMS: To assess the potential association between the change in diameter of colorectal liver metastases between pre-operative imaging and liver resection and disease-free survival in patients who do not receive pre-operative liver-directed chemotherapy. MATERIALS AND METHODS: Analysis of a prospectively maintained database of patients undergoing liver resection for colorectal liver metastases between 2005 and 2012 was undertaken. Change in tumour size was assessed by comparing the maximum tumour diameter at radiological diagnosis determined by imaging and the maximum tumour diameter measured at examination of the resected specimen in 157 patients. RESULTS: The median interval from first scan to surgery was 99 days and the median increase in tumour diameter in this interval was 38%, equivalent to a tumour doubling time (DT) of 47 days. Tumour DT prior to liver resection was longer in patients with T1 primary tumours (119 days) than T2-4 tumours (44 days) and shorter in patients undergoing repeat surgery for intra-hepatic recurrence (33 days) than before primary resection (49 days). The median disease-free survival of the whole cohort was 1.57 years (0.2-7.3) and multivariate analysis revealed no association between tumour DT prior to surgery and disease-free survival. CONCLUSIONS: The rate of growth of colorectal liver metastases prior to surgery should not be used as a prognostic factor when considering the role of resection.

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group.

BACKGROUND: Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas. METHODS: This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS). RESULTS: 1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality. CONCLUSION: This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

The Interaction between Diabetes, Body Mass Index, Hepatic Steatosis, and Risk of Liver Resection: Insulin Dependent Diabetes Is the Greatest Risk for Major Complications.

Background. This study aimed to assess the relationship between diabetes, obesity, and hepatic steatosis in patients undergoing liver resection and to determine if these factors are independent predictors of major complications. Materials and Methods. Analysis of a prospectively maintained database of patients undergoing liver resection between 2005 and 2012 was undertaken. Background liver was assessed for steatosis and classified as <33% and ≥33%. Major complications were defined as Grade III-V complications using the Dindo-Clavien classification. Results. 504 patients underwent liver resection, of whom 56 had diabetes and 61 had steatosis ≥33%. Median BMI was 26 kg/m(2) (16-54 kg/m(2)). 94 patients developed a major complication (18.7%). BMI ≥ 25 kg/m(2) (P = 0.001) and diabetes (P = 0.018) were associated with steatosis ≥33%. Only insulin dependent diabetes was a risk factor for major complications (P = 0.028). Age, male gender, hypoalbuminaemia, synchronous bowel procedures, extent of resection, and blood transfusion were also independent risk factors. Conclusions. Liver surgery in the presence of steatosis, elevated BMI, and non-insulin dependent diabetes is not associated with major complications. Although diabetes requiring insulin therapy was a significant risk factor, the major risk factors relate to technical aspects of surgery, particularly synchronous bowel procedures.

Assessment of the value of MRI scan in addition to CT in the pre-operative staging of colorectal liver metastases.

PURPOSE: The aims of this study were to measure the accuracy of computerised tomography (CT) and magnetic resonance imaging (MRI) scans in detecting colorectal liver metastases (CRLM) and to determine if patients who are staged with MRI in addition to CT have longer liver recurrence-free survival compared to those having CT alone in a unit performing routine intra-operative ultrasound. METHODS: A retrospective analysis of patients undergoing liver resection for CRLM was performed. Patients staged pre-operatively with CT or with additional MRI were included and those with additional PET imaging were excluded from survival analysis. Timing and site of tumour recurrence were recorded. RESULTS: During a 7-year period, 303 patients underwent resection for CRLM of whom 47 (15.5 %) were staged with CT alone and 36 (11.9 %) with additional MRI. The overall accuracy of CT (63 %) and MRI (61.9 %) was similar in the detection of tumour nodules (P = 0.905). There was no difference in the rate of intra-hepatic recurrence between groups with 13/47 and 8/36 cases, respectively (P = 0.737). There was no difference in the disease-free survival curves between the groups (P = 0.487). CONCLUSIONS: Our recommendation is that MRI should not be a mandatory imaging modality in referral guidelines for patients with hepatic CRLM, as the cost and delay associated with the scan outweigh any potential benefit in terms of improved sensitivity compared to CT.

Renal dysfunction is an independent risk factor for mortality after liver resection and the main determinant of outcome in posthepatectomy liver failure.

Introduction. The aim of this study was to assess the interaction of liver and renal dysfunction as risk factors for mortality after liver resection. Materials and Methods. A retrospective analysis of 501 patients undergoing liver resection in a single unit was undertaken. Posthepatectomy liver failure (PHLF) was defined according to the International Study Group of Liver Surgery (ISGLS) definition (assessed on day 5) and renal dysfunction according to RIFLE criteria. 90-day mortality was recorded. Results. Twenty-three patients died within 90 days of surgery (4.6%). The lowest mortality occurred in patients without evidence of PHLF or renal dysfunction (2.7%). The mortality rate in patients with isolated PHLF or renal dysfunction was 20% compared to 45% in patients with both. Diabetes (P = 0.028), renal dysfunction (P = 0.030), and PHLF on day 5 (P = 0.011) were independent predictors of 90-day mortality. Discussion. PHLF and postoperative renal dysfunction are independent predictors of 90-day mortality following liver resection but the predictive value for mortality is significantly higher when failure of both organ systems occurs simultaneously.

The Preoperative Assessment of Hepatic Tumours: Evaluation of UK Regional Multidisciplinary Team Performance.

Introduction. In the UK, patients where liver resection is contemplated are discussed at hepatobiliary multidisciplinary team (MDT) meetings. The aim was to assess MDT performance by identification of patients where radiological and pathological diagnoses differed. Materials and Methods. A retrospective review of a prospectively maintained database of all cases undergoing liver resection from March 2006 to January 2012 was performed. The presumed diagnosis as a result of radiological investigation and MDT discussion is recorded at the time of surgery. Imaging was reviewed by specialist gastrointestinal radiologists, and resultswereagreedonby consensus. Results. Four hundred and thirty-eight patients were studied. There was a significant increase in the use of preoperative imaging modalities (P ≤ 0.01) but no change in the rate of discrepant diagnosis over time. Forty-two individuals were identified whose final histological diagnosis was different to that following MDT discussion (9.6%). These included 30% of patients diagnosed preoperatively with hepatocellular carcinoma and 25% with cholangiocarcinoma of a major duct. Discussion. MDT assessment of patients preoperatively is accurate in terms of diagnosis. The highest rate of discrepancies occurred in patients with focal lesions without chronic liver disease or primary cancer, where hepatocellular carcinoma was overdiagnosed and peripheral cholangiocarcinoma underdiagnosed, where particular care should be taken. Additional care should be taken in these groups and preoperative multimodality imaging considered.

Partial Preservation of Segment IV Confers No Benefit When Performing Extended Right Hepatectomy for Colorectal Liver Metastases.

Introduction. Reducing the volume of resected liver parenchyma may lead to lower morbidity and mortality. The aim of this study was to determine whether partial preservation of segment IV leads to improved outcomes when undertaking extended right hepatectomy for colorectal liver metastases (CRLM). Materials and Methods. A retrospective analysis of patients undergoing right-sided hepatectomy for CRLM was performed. Rates of 90-day mortality and organ dysfunction were compared in 117 patients undergoing right hepatectomy (n = 85), partially extended right hepatectomy with preservation of part of segment IV (n = 20), and fully extended right hepatectomy (n = 12). Results. The 90-day mortality rate of those undergoing right hepatectomy (3/85) was similar to that of those undergoing extended right hepatectomy (0/12) (P = 1.000) but lower than that of those undergoing partially extended right hepatectomy (4/20) (P = 0.024). The rates of hepatic and renal dysfunction were similar between patients undergoing right hepatectomy, partially extended or extended hepatectomy. Discussion. Preservation of part of segment IV confers little clinical benefit when performing extended right hepatectomy for CRLM.

Five-year prospective follow-up of 430 laparoscopic totally extraperitoneal inguinal hernia repairs in 275 patients.

INTRODUCTION: Favourable short-term results, with respect to less postoperative pain and earlier return to physical activity, have been demonstrated with laparoscopic totally extraperitoneal (TEP) hernia repair compared with open mesh repair. However, there is limited data regarding long-term results. PATIENTS AND METHODS: The study cohort consisted of 275 consecutive patients undergoing TEP repair between 1996 and 2002. Patient demographics, details of surgery, postoperative complications, recurrence and chronic pain were collected from patient records and from a prospective database. All patients were seen at 6 weeks and then annually for 5 years following surgery. RESULTS: A total of 430 repairs were performed in the 275 patients (median age, 56 years; range, 20-94 years; men, 97.5%). Bilateral repair was performed in 168 patients (61.1%) and recurrent hernia repair in 79 patients (28.7%). Two patients were converted to an open procedure. Five-year follow-up was achieved in 72% of patients. Eleven patients (4%) died during the follow-up period due to unrelated causes. Hernia recurrence rate at 5 years was 1.1% per patient (three repairs). Recurrences were noted at 7 months, 2 years and 4 years following surgery. Chronic groin pain was reported by 21 patients (7.6%), seven of whom required referral to the pain team. CONCLUSIONS: TEP hernia repair is associated with a recurrence rate of 1% at 5 years in this series. Chronic groin symptoms are also acceptably few. This recurrence rate following TEP repair compares extremely favourably with open mesh repair, particularly as it includes a high proportion of recurrent repairs. As well as the proven early benefits, TEP repair can be considered a safe and durable procedure with excellent long-term results.