Adrian Ben Cresswell

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

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.

Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy

OBJECTIVES There is debate concerning the best mode of delivery of analgesia following liver resection, with continuous i.m. infusion of bupivacaine (CIB) plus patient-controlled i.v. analgesia (PCA) suggested as an alternative to continuous epidural analgesia (CEA). This study compares these two modalities. METHODS A total of 498 patients undergoing major hepatectomy between July 2004 and July 2011 were included. Group 1 received CIB + PCA (n = 429) and Group 2 received CEA (n = 69). Groups were analysed on baseline patient and surgical characteristics. Primary endpoints were pain severity scores and total opioid consumption. Secondary endpoints were pain management failures, need for rescue medication, postoperative (opioid-related) morbidity and hospital length of stay (LoS). RESULTS In both groups pain was well controlled and >70% of patients had no or minimal pain on PoDs 1 and 2. The numbers of patients experiencing severe pain were similar in both groups: PoD 1 at rest: 0.3% in Group 1 and 0% in Group 2 (P = 1.000); PoD 1 on movement: 8% in Group 1 and 2% in Group 2 (P = 0.338); PoD 2 at rest: 0% in Group 1 and 2% in Group 2 (P = 0.126), and PoD 2 on movement: 5% in Group 1 and 5% in Group 2 (P = 1.000). Although the CIB + PCA group required more opioid rescue medication on PoD 0 (53% versus 22%; P < 0.001), they used less opioids on PoDs 0-3 (P ≤ 0.001), had lower morbidity (26% versus 39%; P = 0.018), and a shorter LoS (7 days versus 8 days; P = 0.005). CONCLUSIONS The combination of CIB + PCA provides pain control similar to that provided by CEA, but facilitates lower opioid consumption after major hepatectomy. It has the potential to replace epidural analgesia, thereby avoiding the occurrence of rare but serious complications.

Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy

BACKGROUND Control of hepatic inflow is a key manoeuvre during right hepatectomy and has traditionally been achieved by extrahepatic dissection of the component right portal inflow structures at the hepatic hilum. An alternative technique is the anterior intrahepatic approach (AIA), in which the Glissonian sheath is isolated within the substance of the liver during parenchymal transection and secured using an endovascular stapling device. This study evaluates the intrahepatic, extra-Glissonian technique in comparison with classical extrahepatic dissection (EHD) in right hepatectomy. METHODS A retrospective case-controlled study referring to a 20-year period identified 342 consecutive patients who underwent right hepatectomy for colorectal liver metastases from a prospectively compiled database. The AIA to right hepatectomy was used in 182 of these patients and the extrahepatic approach in 160. The two groups were matched for age, gender, stage of primary tumour and number and size of metastases. Outcome measures included safety factors (bleeding, bile duct injury and gun failure), operative duration, oncological margin, morbidity and mortality. RESULTS There were no significant differences between the two groups in terms of operative duration (240 min vs. 260 min) or postoperative change in haemoglobin (1.3 g/dl vs. 1.4 g/dl). The AIA was associated with lower operative blood loss (355 ml vs. 425 ml; P < or = 0.001), a reduced rate of significant morbidity (14.6% vs. 23.1%; P = 0.005), better R0 resection rates (93% vs. 89%; P = 0.014) and a lower 90-day mortality rate (3% vs. 7%; P = 0.046). There was one minor bile leak in each group, two clinically significant bile leaks requiring endoscopic retrograde cholangiopancreatography and stenting in the extrahepatic group, and a further persistent bile leak requiring biliary reconstruction in each group. In two instances the endovascular stapler misfired. Both cases were dealt with at the time of surgery with no further sequelae. The length of hospital stay was equivalent in the two groups (8 days vs. 9 days). CONCLUSIONS In selected patients, intrahepatic, extra-Glissonian stapled right hepatectomy is feasible, safe and avoids the need for EHD. The anterior approach to right hepatectomy may achieve outcomes at least as good as those associated with the classical extrahepatic approach.

Radiological anatomy of the abdomen

Abstract Advances in technology have led to significant developments in techniques for imaging the abdominal and pelvic organs, in both the elective and emergency surgical settings. Improvements in the quality and availability of imaging has had a profound effect on the delivery of high-quality surgical care and has improved outcomes by providing accurate preoperative diagnosis and staging, leading to a reduction in exploratory and futile operations, while permitting better planned precision surgery and a growing range of interventional radiology interventions. This article will describe the essential anatomical interpretation of the common radiological imaging techniques relevant to the abdomen and pelvis and describe the rationale for selection of the most appropriate imaging modality.

PTU-265 Long term survival after the liver first approach for synchronous colorectal liver metastases: a single centre propensity score case-matched analysis

Introduction Liver resection prior to resection of the primary cancer is a novel strategy advocated for selected patients presenting with synchronous colorectal liver metastases (sCRLM). This study measured outcomes in patients with sCRLM, following a liver-first (LFA) or classical approach (CA) and used a validated propensity score, the Basingstoke Predictive Index (BPI), to determine differences in survival between case-matched groups. Method Clinical, pathologic, and complete follow-up (median 34 months) data were prospectively recorded from 582 consecutive patients undergoing hepatic resection for sCRLM at a single centre (2004–2014). 98 patients had a LFA and 467 had a CA to treatment. 17 patients who had a simultaneous bowel and liver resection were excluded. Cumulative disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) were calculated using Kaplan Meier analysis. Results The LFA group had significantly more patients with rectal cancer (44.9% vs. 27.8%, p = 0.001) or poorly differentiated primaries (17.3% vs. 9%, p = 0.001), had a higher median [interquartile range (IQR)] number of sCRLM [3 (1–20) versus 2 (0–19), p = 0.0007] and size (in millimetres) of sCRLM [17 (3–24), versus 15 (2–29), p = 0.023], compared to the CA patients. Moreover, the median (IQR) preoperative BPI was significantly higher in the LFA group [8.5 (5–10)], versus CA group [8.0 (4–9), p = 0.03]. 73.5% of LFA patients had neoadjuvant chemotherapy, compared to 59.7% in the CA group (p = 0.01). Whilst more LFA patients had a major liver resection (69.4% vs. 56.5%, p = 0.018), there was no difference in Clavien-Dindo grade 3/4 complications (10.2% vs. 7.1%, p = 0.392), median (IQR) length of stay in days [6 (4–9) versus 6 (5–8), p = 0.835] or 30-day mortality [2% vs. 0.2%, p = 0.079] compared to the CA group. The 5 year DFS was 22.8% in the LFA group, significantly lower than the CA group (45.6%, p = 0.001). However there was no difference in 5 year CSS (53.8% vs. 51.1%, p = 0.379) or OS between groups (43.7% vs. 49.6%, p = 0.305). When patients were matched for pre-operative BPI, there was no statistical difference in either 5 year DFS (37% vs. 41.2%, p = 0.083), CSS (53.2% vs. 51.2%, p = 0.616) or OS (44.9% vs. 49.8%, p = 0.846) between groups. Conclusion In our unit, patients with sCRLM selected for a LFA were a group with more oncologically advanced disease and a poorer prognosis. These patients had a significantly inferior cumulative DFS compared to patients selected for a CA. However, there was no significant difference in cumulative DFS when prognostic variables were matched according to preoperative BPI. These data provide further evidence to support a LFA in selected patients with sCRLM. Disclosure of interest None Declared.