Brian R. Davidson

Guidelines for the diagnosis and treatment of cholangiocarcinoma: consensus document

### 1.1 Development of guidelines There is currently no clear national consensus for the optimal diagnosis and treatment of cholangiocarcinoma. The need for these guidelines was highlighted following the annual meeting of the British Association for the Study of the Liver (BASL) in September 2000. During their development these guidelines were presented at a BASL Liver Cancer Workshop in January 2001. They were also circulated to BASL members and the Liver Section of the British Society of Gastroenterology (BSG) Committee members, including gastroenterologists, hepatologists, gastroenterological surgeons, pathologists, radiologists, and epidemiologists for comments before the final consensus document was drawn up. ### 1.2 Strategy The guidelines are based on comprehensive literature surveys including results from randomised controlled trials, systematic reviews and meta-analyses, and cohort, prospective, and retrospective studies. On issues where no significant study data were available, evidence was obtained from expert committee reports or opinions. Where possible, specific recommendations have been graded, based on the quality of evidence available (section 2.4). ### 1.3 Context and intent These guidelines are intended to bring consistency and improvement in the patient’s management from first suspicion of cholangiocarcinoma through to confirmation of the diagnosis and subsequent management. As stated in previous BSG guidelines, patient preferences must be sought and decisions made jointly by the patient and health carer, based on the risks and benefits of any intervention. Furthermore, the guidelines should not necessarily be regarded as the standard of care for all patients. Individual cases must be managed on the basis of all clinical data available for that case. The guidelines are subject to change in light of future advances in scientific knowledge. Mortality rates from intrahepatic cholangiocarcinoma have risen steeply and steadily over the past 30 years and since the mid 1990s more deaths have been coded annually in England and Wales as being due to this tumour than to hepatocellular carcinoma.1 In 1997 and …

Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update.

The British Society of Gastroenterology guidelines on the management of cholangiocarcinoma were originally published in 2002. This is the first update since then and is based on a comprehensive review of the recent literature, including data from randomised controlled trials, systematic reviews, meta-analyses, cohort, prospective and retrospective studies.

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery

Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience.

Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.

Liver ischemia/reperfusion injury: Processes in inflammatory networks—A review

Liver ischemia/reperfusion (IR) injury is typified by an inflammatory response. Understanding the cellular and molecular events underpinning this inflammation is fundamental to developing therapeutic strategies. Great strides have been made in this respect recently. Liver IR involves a complex web of interactions between the various cellular and humoral contributors to the inflammatory response. Kupffer cells, CD4+ lymphocytes, neutrophils, and hepatocytes are central cellular players. Various cytokines, chemokines, and complement proteins form the communication system between the cellular components. The contribution of the danger‐associated molecular patterns and pattern recognition receptors to the pathophysiology of liver IR injury are slowly being elucidated. Our knowledge on the role of mitochondria in generating reactive oxygen and nitrogen species, in contributing to ionic disturbances, and in initiating the mitochondrial permeability transition with subsequent cellular death in liver IR injury is continuously being expanded. Here, we discuss recent findings pertaining to the aforementioned factors of liver IR, and we highlight areas with gaps in our knowledge, necessitating further research. Liver Transpl 16:1016–1032, 2010.

The contemporary role of antioxidant therapy in attenuating liver ischemia‐reperfusion injury: A review

Oxidative stress is an important factor in many pathological conditions such as inflammation, cancer, ageing and organ response to ischemia‐reperfusion. Humans have developed a complex antioxidant system to eliminate or attenuate oxidative stress. Liver ischemia‐reperfusion injury occurs in a number of clinical settings, including liver surgery, transplantation, and hemorrhagic shock with subsequent fluid resuscitation, leading to significant morbidity and mortality. It is characterized by significant oxidative stress but accompanied with depletion of endogenous antioxidants. This review has 2 aims: firstly, to highlight the clinical significance of liver ischemia‐reperfusion injury, the underlying mechanisms and the main pathways by which the antioxidants function, and secondly, to describe the new developments that are ongoing in antioxidant therapy and to present the experimental and clinical evidence about the role of antioxidants in modulating hepatic ischemia‐reperfusion injury. (Liver Transpl 2005;11:1031–1047.)

Recommendations for management of patients with neuroendocrine liver metastases

Many management strategies exist for neuroendocrine liver metastases. These strategies range from surgery to ablation with various interventional radiology procedures, and include both regional and systemic therapy with diverse biological, cytotoxic, or targeted agents. A paucity of biological, molecular, and genomic information and an absence of data from rigorous trials limit the validity of many publications detailing management. This Review represents the views from an international conference, for which 15 expert working groups prepared evidence-based assessments addressing specific questions, and from which an independent jury derived final recommendations. The aim of the conference was to review the existing approaches to neuroendocrine liver metastases, assess the evidence on which management decisions were based, develop internationally acceptable recommendations for clinical practice (when evidence was available), and make recommendations for clinical and research endeavours. This report represents the final clinical statements and proposals for future research.

Risk factors for recurrence of primary sclerosing cholangitis after liver transplantation

Liver transplantation (LT) is the only therapeutic option for end‐stage primary sclerosing cholangitis (PSC), but PSC can recur (rPSC) in some patients after LT. The aim of our study was to evaluate the risk factors associated with rPSC. Between 1989 and 2004, 69 patients receiving transplantation for PSC (42 male, mean age 41.9 yr). Clinical and laboratory data, activity/extension and treatment of ulcerative colitis (UC), post‐LT cytomegalovirus (CMV) infection, and immunosuppression were evaluated. Determination of rPSC was made by radiological and histological findings. Exclusion criteria were ABO blood group incompatibility, hepatic artery stenosis, and biliary strictures occurring in <3 months post‐LT. A total of 48 (70%) patients had PSC and UC pre‐LT. rPSC occurred in 7 of 53 (13.5%, 2 patients with de novo UC) who were alive 1 yr after LT and/or met inclusion/exclusion criteria: median 60 (4‐120) months. No patient without post‐LT UC had rPSC: 0 of 20 vs. 7 of 26 with post‐LT UC (P = 0.027). The multivariate logistic regression analysis showed that maintenance steroids for UC (>3 months) post‐LT was the only risk factor significantly associated with rPSC (P = 0.025). In conclusion, the presence of UC post‐LT, and the need for maintenance steroids post‐LT, which is an independent factor, are associated with rPSC. These findings could help elucidate a possible mechanism of PSC pathogenesis. Liver Transpl, 2007.

Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy

Although day‐case laparoscopic cholecystectomy can save bed costs, its safety has to be established. The aim of this meta‐analysis is to assess the advantages and disadvantages of day‐case surgery compared with overnight stay in patients undergoing elective laparoscopic cholecystectomy.

Assessment of risk of bias in randomized clinical trials in surgery.

Meta‐analysis of randomized clinical trials (RCTs) with low risk of bias is considered the highest level of evidence available for evaluating an intervention. Bias in RCTs may overestimate or underestimate the true effectiveness of an intervention.