A comparative study of risk factors for pancreatic fistula after pancreatoduodenectomy or distal pancreatectomy.

BACKGROUND: Evidence associates various biometric and histological variables such as steatosis and absence of fibrosis as risk factors for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Following distal pancreatectomy (DP), the association between these factors and POPF is less clear. This study of patients, drawn from the same background population, undergoing PD or DP at a single centre is a comparative study of the risk factors for POPF after these two operations. METHODS: Associations between POPF and patient characteristics, pre-operative blood tests, data from pre-operative computed tomography (CT) imaging, assessment of histological steatosis and fibrosis were explored. RESULTS: 26/107 (24%) and 26/90 (29%) patients developed POPF after PD and DP respectively. Absence of fibrosis was associated with POPF (p < 0.001) after PD and its presence correlated with pancreatic duct width (p < 0.001). Steatosis was not associated with POPF (p = 0.910). Multivariable analysis showed pancreatic duct width (p = 0.016) and fibrosis (p = 0.025) to be independent predictors of POPF after PD. The only variable associated with POPF after DP was underlying pathology (p = 0.005). CONCLUSION: Pancreatic duct width is the most important variable related to POPF after PD and is correlated with fibrosis. Steatosis was not related to POPF. In contrast, after DP POPF appears to be related to the underlying disease.

A Donation After Circulatory Death Program Has the Potential to Increase the Number of Donors After Brain Death.

OBJECTIVES: Donation after circulatory death has been responsible for 75% of the increase in the numbers of deceased organ donors in the United Kingdom. There has been concern that the success of the donation after circulatory death program has been at the expense of donation after brain death. The objective of the study was to ascertain the impact of the donation after circulatory death program on donation after brain death in the United Kingdom. DESIGN: Retrospective cohort study. SETTING: A national organ procurement organization. PATIENTS: Patients referred and assessed as donation after circulatory death donors in the United Kingdom between October and December 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 257 patients were assessed for donation after circulatory death. Of these, 193 were eligible donors. Three patients were deemed medically unsuitable following surgical inspection, 56 patients did not proceed due to asystole, and 134 proceeded to donation. Four donors had insufficient data available for analysis. Therefore, 186 cases were analyzed in total. Organ donation would not have been possible in 79 of the 130 actual donors if donation after circulatory death was not available. Thirty-six donation after circulatory death donors (28% of actual donors) were judged to have the potential to progress to brain death if withdrawal of life-sustaining treatment had been delayed by up to a further 36 hours. A further 15 donation after circulatory death donors had brain death confirmed or had clinical indications of brain death with clear mitigating circumstances in all but three cases. We determined that the maximum potential donation after brain death to donation after circulatory death substitution rate observed was 8%; however due to mitigating circumstances, only three patients (2%) could have undergone brain death testing. CONCLUSIONS: The development of a national donation after circulatory death program has had minimal impact on the number of donation after brain death donors. The number of donation after brain death donors could increase with changes in end-of-life care practices to allow the evolution of brain death and increasing the availability of ancillary testing.

Accepting multiple simultaneous liver offers does not negatively impact transplant outcomes.

Impact of performing multiple liver transplants (LT) in a short period of time is unknown. Consecutively performed LT potentially increase complication rates through team fatigue and overutilization of resources and increase ischemia time. We analyzed the impact of undertaking consecutive LT (Consecutive liver transplant, CLT; LT preceded by another transplant performed not more than 12 h before, both transplants grouped together) on outcomes. Of 1702 LT performed, 314 (18.4%) were CLT. Outcome data was compared with solitary LT (SLT; not more than one LT in 12-h period). Recipient, donor, and graft characteristics were evenly matched between SLT and CLT; second LT of CLT group utilized younger donors grafts with longer cold ischemic times (P = 0.015). Implantation and operative time were significantly lower in CLT recipients on intergroup analysis (P = 0.0001 and 0.002, respectively). Early hepatic artery thrombosis (E-HAT) was higher in CLT versus SLT (P = 0.038), despite absolute number of E-HAT being low in all groups. Intragroup analysis demonstrated a trend toward more frequent E-HAT in first LT, compared to subsequent transplants; however, difference did not reach statistical significance (P = 0.135). In era of organ scarcity, CLT performed at high-volume center is safe and allows pragmatic utilization of organs, potentially reducing number of discarded grafts and reducing waiting list mortality.

Should We Reject Donated Organs on Moral Grounds or Permit Allocation Using Non-Medical Criteria?: A Qualitative Study.

Conditional and directed deceased organ donations occur when donors (or often their next of kin) attempt to influence the allocation of their donated organs. This can include asking that the organs are given to or withheld from certain types of people, or that they are given to specified individuals. Donations of these types have raised ethical concerns, and have been prohibited in many countries, including the UK. In this article we report the findings from a qualitative study involving interviews with potential donors (n = 20), potential recipients (n = 9) and transplant staff (n = 11), and use these results as a springboard for further ethical commentary. We argue that although participants favoured unconditional donation, this preference was grounded in a false distinction between 'medical' and 'non-medical' allocation criteria. Although there are good reasons to maintain organ allocation based primarily upon the existing 'medical' criteria, it may be premature to reject all other potential criteria as being unacceptable. Part of participants' justification for allocating organs using 'medical' criteria was to make the best use of available organs and avoid wasting their potential benefit, but this can also justify accepting conditional donations in some circumstances. We draw a distinction between two types of waste - absolute and relative - and argue that accepting conditional donations may offer a balance between these forms of waste.

An Empirically Informed Analysis of the Ethical Issues Surrounding Split Liver Transplantation in the United Kingdom.

Surgical advances have allowed for the development of split liver transplantation, providing two recipients with the opportunity to potentially benefit from one donated liver by splitting the liver into two usable parts. Although current data suggest that the splitting of livers provides overall benefit to the liver-recipient population, relatively low numbers of livers are actually split in the United Kingdom. This article addresses the question of whether ethical concerns are posing an unnecessary barrier to further increasing the number of life-saving transplantations. Recognizing that an important aspect of exploring these concerns is gaining insight into how transplant staff and patients regard splitting livers, the article presents the findings of a qualitative study examining the views of senior transplant staff and liver transplant patients in the UK and uses these to inform a commentary on the ethical issues relating to split liver transplantation.

Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques.

Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I-IV), and biliary reconstruction was classified into 2 groups [duct-to-duct (DD) anastomosis and Roux-en-Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (P = 0.009 and P = 0.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (P = 0.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (P = 0.04 and P = 0.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high-risk reconstructive techniques.

Early occurrence of new-onset diabetes after transplantation is related to type of liver graft and warm ischaemic injury.

BACKGROUND & AIMS: We studied new-onset diabetes after transplantation (NODAT) in liver transplantation with grafts donated after brain death (DBD) or circulatory death (DCD), focusing on the early post-transplant period. METHODS: A total of 430 non-diabetic primary liver transplant recipients [DCD, n = 90 (21%)] were followed up for 30 months (range 5-69). NODAT was defined as the composite endpoint of one of following: (i) Two non-fasting plasma glucose levels > 11.1 mmol/L ≥ 30 days apart, (ii) oral hypoglycaemic drugs ≥ 30 days consecutively (iii) insulin therapy ≥ 30 days and (iv) HbA1c ≥ 48 mmol/L. Resolution of NODAT was defined as cessation of treatment or hyperglycaemia. RESULTS: Total of 81/430 (19%) patients developed NODAT. Incidence and resolution of NODAT over time showed significantly different patterns between DCD and DBD liver graft recipients; early occurrence, high peak incidence and early resolution were seen in DCD. In multivariate logistic regression including age, ethnicity, HCV, tacrolimus level and pulsed steroids, only DCD was independently associated with NODAT at day 15 post-transplant (OR 6.5, 95% CI 2.3-18.4, P < 0.001), whereas age and pulsed steroids were significant factors between 30-90 days. Combined in multivariate Cox regression model for NODAT-free survival, graft type, age and pulsed steroids were each independent predictor for decreased NODAT-free survival in the first 90-postoperative days. CONCLUSION: Early peak of NODAT in DCD graft recipients is a novel finding, occurring independently from known risk factors. Donor warm ischaemia and impact on insulin sensitivity should be further studied and could perhaps be associated with graft function.

Predictors of early recurrence after resection of colorectal liver metastases.

BACKGROUND: Early recurrence after resection of colorectal liver metastases (CLM) is common. Patients at risk of early recurrence may be candidates for enhanced preoperative staging and/or earlier postoperative imaging. The aim of this study was to determine if there are any risk factors that specifically predict early liver-only and systemic recurrence. METHODS: Retrospective analysis of prospective database of patients undergoing liver resection (LR) for CLM from 2004 to 2006 was undertaken. Early recurrence was defined as occurring within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors were compared between patients with and without early recurrence. RESULTS: Two hundred and forty-three consecutive patients underwent LR for CLM. Twenty-seven patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence (P < 0.05). Sixty-six patients (27%) developed early systemic recurrence. Tumour size ≥3.6 cm and tumour number (>2) were significantly associated with early systemic recurrence (P < 0.001). CONCLUSIONS: It is possible to stratify patients according to the risk of early liver-only or systemic recurrence after resection of CLM. High-risk patients may be candidates for preoperative MRI and/or computed tomography-positron emission tomography (CT-PET) scan and should receive intensive postoperative surveillance.

Etiology and management of hepatic artery thrombosis after adult liver transplantation.

Hepatic artery thrombosis (HAT) represents a major cause of graft loss and mortality after liver transplantation. It occurs in up to 9% of adult recipients. The early diagnosis of HAT decreases septic complications, multiorgan failure, and graft loss, and there are better outcomes after treatment. In this study, we reviewed 102 episodes of HAT, which were classified as early hepatic artery thrombosis (E-HAT) when they were diagnosed within the first 21 days after transplantation. The overall incidence of HAT was 7%: 31 episodes (30.4%) were identified as E-HAT, and 71 episodes (69.6%) were identified as late hepatic artery thrombosis (L-HAT). Graft dysfunction was the commonest presentation (30 cases or 29%). Most E-HAT cases were managed with retransplantation (74%), whereas early revascularization was carried out for only 13% with a 75% success rate. The incidence of retransplantation for L-HAT was only 41%, whereas 32% were too ill for relisting and eventually died. Successful conservative management was noted for 13 of the 102 patients (13%) with collateralization and good hepatic perfusion, with biliary complications encountered in 7 cases (54%) subsequently. A multivariate analysis showed that previous episodes of HAT, the number of arterial anastomoses, and a low donor weight were independent risk factors for E-HAT, whereas a history of upper abdominal operations (non-HAT), a previous history of HAT, a low donor weight, and a recipient age < 50 years were independent risk factors for L-HAT. The graft survival rates for HAT patients were 52%, 36.6%, and 27.4% at 1, 3, and 5 years, whereas the corresponding rates were 81.4%, 81.2%, and 76.4% for non-HAT patients. In conclusion, prompt revascularization for E-HAT patients decreases the incidence of serious, irreversible septic complications and graft loss and improves overall outcomes. A significant number of L-HAT patients do not require further intervention despite the high incidence of ischemic cholangiopathy.

Increasing the donor pool: consideration of prehospital cardiac arrest in controlled donation after circulatory death for liver transplantation.

Donor warm ischemia has implications for outcomes after liver transplantation (LT) using organs from donation after circulatory death (DCD) donors. Prehospital cardiac arrest (PHCA) before donation may generate a further ischemic insult. The aim of this single-center study of 108 consecutive DCD LT procedures was to compare the outcomes of PHCA and non-PHCA cohorts. A review of a prospectively collected database of all DCD grafts transplanted between January 2007 and October 2011 was undertaken to identify donors who had sustained PHCA. The unit policy was to consider such donors when transaminase levels were ≤4 times the normal range and had an improving trend. Twenty-six of the 108 DCD transplants were from DCD donors with PHCA, and 82 were in the non-PHCA cohort. A comparative analysis of the PHCA and non-PHCA cohorts showed better short-term results (a low incidence of acute kidney injury) for the PHCA group but satisfactory long-term results for both groups with no significant differences in graft or patient survival between them. In conclusion, a careful donor selection policy for including PHCA DCD donors with normalized liver function tests or transaminase levels ≤ 4 times the norm resulted in successful transplantation and could boost the donor pool with no adverse outcomes.

Live liver donation, ethics and practitioners: 'I am between the two and if I do not feel comfortable about this situation, I cannot proceed'.

This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations (LLDs). Donations between emotionally related donor and recipients (especially from parents to their children) increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals (HCPs) disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of donor versus recipient. Participants' views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation (LKD) were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD.

Repeat liver resection for recurrent colorectal metastases: a single-centre, 13-year experience.

OBJECTIVES: Isolated intrahepatic recurrence is noted in up to 40% of patients following curative liver resection for colorectal liver metastases (CLM). The aims of this study were to analyse the outcomes of repeat hepatectomy for recurrent CLM and to identify factors predicting survival. METHODS: Data for all liver resections for CLM carried out at one centre between 1998 and 2011 were analysed. RESULTS: A total of 1027 liver resections were performed for CLM. Of these, 58 were repeat liver resections performed in 53 patients. Median time intervals were 10.5 months between the primary resection and first hepatectomy, and 15.4 months between the first and repeat hepatectomies. The median tumour size was 3.0 cm and the median number of tumours was one. Six patients had a positive margin (R1) resection following first hepatectomy. There were no perioperative deaths. Significant complications included transient liver dysfunction in one and bile leak in two patients. Rates of 1-, 3- and 5-year overall survival following repeat liver resection were 85%, 61% and 52%, respectively, at a median follow-up of 23 months. R1 resection at first hepatectomy (P = 0.002), a shorter time interval between the first and second hepatectomies (P = 0.02) and the presence of extrahepatic disease (P = 0.02) were associated with significantly worse overall survival. CONCLUSIONS: Repeat resection of CLM is safe and can achieve longterm survival in carefully selected patients. A preoperative knowledge of poor prognostic factors helps to facilitate better patient selection.

How severe is diabetes after total pancreatectomy? A case-matched analysis.

OBJECTIVES: Total pancreatectomy (TP) is associated with significant morbidity and mortality. The severity of postoperative diabetes and existence of 'brittle diabetes' are unclear. This study sought to identify quality of life (QoL) and diabetes-specific outcomes after TP. METHODS: Patients who underwent TP were matched for age, sex and duration of diabetes with patients with type 1 diabetes. General QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) core quality of life questionnaire QLQ-C30 and the PAN26 tool. Diabetes-specific outcomes were assessed using the Problem Areas in Diabetes (PAID) tool and an assessment of diabetes-specific complications and outcomes. RESULTS: A total of 123 patients underwent TP; 88 died (none of diabetic complications) and two were lost to follow-up. Of the remaining 33 patients, 28 returned questionnaires. Fourteen general and pancreas-specific QoL measurements were all significantly worse amongst the TP cohort (QLQ-C30 + PAN26). However, when diabetes-specific outcomes were compared using the PAID tool, only one of 20 was significantly worse. HbA1c values were comparable (P = 0.299), as were diabetes-related complications such as hypoglycaemic attacks and organ dysfunction. CONCLUSIONS: Total pancreatectomy is associated with impaired QoL on general measures compared with that in type 1 diabetes patients. Importantly, however, there was almost no significant difference in diabetes-specific outcomes as assessed by a diabetes-specific questionnaire, or in diabetes control. This study does not support the existence of 'brittle diabetes' after TP.

A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy.

BACKGROUND: Various factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF. METHODS: A post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2 :1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set. RESULTS: Postoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768-0.897; P < 0.001) and successfully tested upon the validation set. CONCLUSIONS: Preoperative assessment of a patient's risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD.

Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low-grade dysplasia.

BACKGROUND: The accurate diagnosis of dysplasia or carcinoma within ampullary lesions can be difficult, but, when possible, identifies patients who require endoscopic or surgical resection, respectively. The role of endoscopic ultrasound (EUS) in diagnosing these lesions and the degree of dysplasia is unclear. METHODS: Patients with lesions of the ampulla were identified over 5 years. Patients who did not undergo EUS were compared with those who did. RESULTS: A total of 27 of 58 (47%) patients were investigated with EUS. Pretreatment diagnoses were correct in 93% of the EUS group vs. 78% of the no-EUS group. Rates of diagnostic accuracy in low-grade dysplasia (LGD), high-grade dysplasia (HGD) and adenocarcinoma (ADC) were 72%, 20% and 96%, respectively, in the no-EUS group, and 93%, 50% and 100%, respectively, in the EUS group. Every diagnosis of LGD in the EUS group was correct, whereas these diagnoses accounted for the majority of errors (eight of 13) in the no-EUS group. High-grade dysplasia was frequently misdiagnosed. More patients were treated by endoscopic resection in the EUS group (12 of 27 vs. five of 31; P= 0.025). CONCLUSIONS: Endoscopic ultrasound increases the accuracy of preoperative diagnosis of ampullary lesions and is particularly useful in patients with LGD because it permits safe endoscopic management. Patients with HGD must be reviewed carefully and considered for pancreatoduodenectomy.

Liver transplantation for acute intermittent porphyria is complicated by a high rate of hepatic artery thrombosis.

Acute intermittent porphyria (AIP) is an autosomal-dominant condition resulting from a partial deficiency of the ubiquitously expressed enzyme porphobilinogen deaminase. Although its clinical expression is highly variable, a minority of patients suffer recurrent life-threatening neurovisceral attacks despite optimal medical therapy. Because the liver is the major source of excess precursor production, liver transplantation (LT) represents a potentially effective treatment for severely affected patients. Using data from the U.K. Transplant Registry, we analyzed all transplants performed for AIP in the United Kingdom and Ireland. Between 2002 and 2010, 10 patients underwent LT for AIP. In all cases, the indication for transplantation was recurrent, biochemically proven, medically nonresponsive acute attacks of porphyria resulting in significantly impaired quality of life. Five patients had developed significant neurological morbidities such as paraplegia before transplantation. The median follow-up time was 23.4 months, and there were 2 deaths from multiorgan failure at 98 days and 26 months. Eight recipients were alive for 3.2 to 109 months after transplantation. Complete biochemical and symptomatic resolution was observed in all patients after transplantation. However, there was a high rate of hepatic artery thrombosis (HAT; 4/10), with 1 patient requiring regrafting. The effects of previous neuronal damage such as joint contractures were not improved by transplantation. Thus, impaired quality of life in the surviving patients was usually a result of preoperative complications. Refractory AIP is an excellent indication for LT, and long-term outcomes for carefully selected patients are good. There is, however, an increased incidence of HAT in these patients, and we recommend routine antiplatelet therapy after transplantation.

Intercurrent infection predicts mortality in patients with late hepatic artery thrombosis listed for liver retransplantation.

Liver retransplantation for late hepatic artery thrombosis (HAT) is considered the treatment of choice for select patients. Nevertheless, there is a paucity of data to aid decision making in this setting. The aims of this single-center study of patients listed for late HAT were (1) to determine variables associated with wait-list mortality, (2) to describe survival after retransplantation, and (3) to determine variables associated with mortality after retransplantation. Seventy-eight patients were diagnosed with late HAT (incidence = 3.9%). Of the 49 patients listed for retransplantation, 9 died on the waiting list and 36 were retransplanted. The estimated 1-year survival after listing for retransplantation was 53.7%. Only multidrug-resistant (MDR) bacteria-positive cultures were predictive of wait-list mortality (P = 0.01). After retransplantation, the estimated 1- and 5-year patient survival was 71.9% and 62.5%, respectively. Increasing Model for End-Stage Liver Disease score (overall P = 0.007), MDR bacteria-positive cultures (P = 0.047), and continued antibiotic therapy (P = 0.001) at the time of retransplantation were risk factors for post retransplant death. In conclusion, patients who undergo liver retransplantation for late HAT have satisfactory outcomes. However, the presence of active infection and MDR bacteria-positive cultures should be taken into account when risk stratifying such patients.

Traumatic focal pancreatitis with retro-duodenal hematoma: a rare cause of combined biliary and gastric outlet obstruction.

CONTEXT: Focal post-traumatic acute pancreatitis causing combined duodenal and biliary obstruction is extremely rare. CASE REPORT: A 16-year-old boy presented with acute upper abdominal pain which was clinically and biochemically consistent with mild acute pancreatitis. There was no etiological factor identified initially, although a history of blunt abdominal trauma was later discovered. He soon developed features of gastric outlet obstruction and obstructive jaundice over 48 hours. A CT scan showed a retroduodenal mass causing compression of both the duodenum and bile duct. At exploration, this was found to be a walled off hematoma. There was evidence of focal pancreatitis in the head of pancreas. Evacuation of the hematoma cured the gastric outlet and biliary obstruction. CONCLUSION: The triad of pancreatitis, gastric outlet and biliary obstruction along with a mass lesion on cross sectional imaging in young adults should raise the suspicion of a hematoma as a probable cause.

Aetio-pathogenesis and the management of spontaneous liver bleeding in the West: a 16-year single-centre experience.

BACKGROUND: Spontaneous liver bleeding (SLB) is a rare but potentially fatal complication. In contrast to the East, various benign pathologies are the source of SLB in the West. An accurate diagnosis and a timely implementation of appropriate treatment are crucial in the management of these patients. The present study presents a large Western experience of SLB from a specialist liver centre. METHODS: A retrospective analysis of patients presented with SLB between January 1995 and January 2011. RESULTS: Sixty-seven patients had SLB, 44 (66%) were female and the median age at presentation was 47 years. Abrupt onset upper abdominal pain was the presenting symptom in 65 (97%) patients. The aetiology for SLB was hepatic adenoma in 27 (40%), hepatocellular carcinoma (HCC) in 17 (25%) and various other liver pathologies in the rest. Emergency treatment included a conservative approach in 42 (64%), DSA and embolization in 6 (9%), a laparotomy and packing in 6 (9%) and a liver resection in 11 (16%) patients. Eleven (16%) patients had further planned treatments. Seven (10%) died during the same admission but the mortality was highest in patients with HELLP syndrome. At a median follow-up of 54 months all patients with benign disease are alive. The 1-, 3- and 5-year survival of patients with HCC was 59%, 35% and 17%, respectively. CONCLUSION: SLB is a life-threatening complication of various underlying conditions and may represent their first manifestation. The management should include initial haemostasis followed by appropriate staging investigations to provide a definitive treatment for each individual patient.