K.R. Prasad

Steatosis predicts postoperative morbidity following hepatic resection for colorectal metastasis

Few studies are available on the effect of steatosis on perioperative outcome following hepatic resection for colorectal liver metastasis (CRLM).

Hepatic resection for metastatic gastrointestinal and pancreatic neuroendocrine tumours: outcome and prognostic predictors

BACKGROUND Treatment modalities for hepatic metastases from neuroendocrine tumours (NETs) include surgery, somatostatin analogues and arterial embolization. The aims of this study were to evaluate the outcome of patients following surgery and to identify prognostic predictors of recurrent disease. PATIENTS AND METHODS This was a retrospective clinico-pathological analysis of patients managed with hepatic NET metastases over a 13-year period (January 1994 to December 2006). RESULTS Eighteen patients with hepatic metastases from NET were identified with a median age of 53 years (range 31-75). The localization of the primary tumour was the terminal ileum (n=8), pancreas (n=7), appendix (n=2) or duodenum (n=1). Twelve patients had synchronous disease and six patients developed metachronous hepatic tumours over a median period of 20 months (range 6-144). Presenting symptoms included abdominal pain (n =13), recurrent diarrhoea (n=7) and flushing (n=7). Fifteen patients underwent surgery with complete cytoreduction and three patients had partial cytoreduction. The overall 2- and 5-year actuarial survival rates were 94% and 86%, respectively. The 2- and 5-year disease-free rates following hepatic resection with complete cytoreduction were both 66%. Partial or complete control of endocrine-related symptoms was achieved in all patients with functioning tumours following surgery. Recurrent disease occurred in four patients following complete cytoreductive surgery. Resection margin involvement was associated with developing recurrent disease (p=0.041). CONCLUSION Surgical resection for hepatic NET metastases results in good long-term survival in selected patients and resection margin involvement was associated with recurrent disease.

C-reactive protein in liver cancer surgery

AIMS The aim of this article is to review the current state of knowledge with regard to the importance of C-reactive protein (CRP) in patients undergoing hepatic resection for malignancy both in terms of its role as an acute phase reactant and predictor of outcome. METHODS An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles that included the search terms: C-reactive protein; CRP; hepatocellular carcinoma; colorectal liver metastases; hepatic resection; and liver resection. RESULTS The limited published data in relation to CRP and liver resection is contradictory. There are studies correlating an acute phase reactant-type postoperative rise in CRP with both good and poor outcome following colorectal liver metastases resection. In relation to prognosis, the only available publication indicates that a high preoperative CRP is a poor prognostic indicator in relation to patient survival. Data for CRP and resection of HCC is equally as limited with early evidence suggesting a correlation between CRP and stage of disease, and documenting an acute temporary elevation in CRP following resection. CONCLUSIONS The importance of CRP as a marker of both early postoperative outcome and long-term prognosis in patients with hepatic malignancies is at present unclear. Further studies are required to clarify the changes and more accurately define the mechanism by which CRP is being up-regulated.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases

The impact of computed tomography (CT)‐based follow‐up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.

Aggressive surgical resection for the management of hepatic metastases from gastrointestinal stromal tumours: a single centre experience

BACKGROUND The outcome of surgical intervention for hepatic metastases from gastrointestinal stromal tumours (GIST) is still uncertain. This study evaluated the outcome of patients following aggressive surgical resection and Imatinib mesylate therapy (IM). PATIENTS AND METHODS This was a retrospective analysis of patients managed with hepatic metastases from GIST over a 13-year period (January 1993 to December 2005). RESULTS Twelve patients were identified with a median age at diagnosis of 62 (32-78) years. The primary sites of GIST were stomach (n=5), jejunum (n=4), sigmoid (n=1), peritoneum (n=1) and pancreas (n=1). Eleven patients underwent surgical resection with curative intent and one patient had cytoreductive surgery. Following surgery with curative intent (n=11), the overall 2- and 5-year survival rates were both 91%, whereas the 2- and 5-year disease-free rates following primary hepatic resection were 30% and 10%, respectively. The median disease-free period was 17 (3-72) months. Eight patients had recurrent disease and were managed with further surgery (n=3), radiofrequency ablation (RFA) (n=2) and IM (n=8). Overall, there are four patients who are currently disease-free: two patients following initial hepatic resection and two patients following further treatment for recurrent disease. There was no significant association in clinicopathological characteristics between patients with recurrent disease within 2 years and patients who were disease-free for 2 years or more. Overall morbidity was 50% (n=6), with one postoperative death. The follow-up period was 43 (3-72) months. CONCLUSION Surgical resection for hepatic GIST metastases may improve survival in selected patients. Recurrent disease can be managed with surgery, RFA and IM.

Mirizzi's syndrome--results from a large western experience.

BACKGROUND This paper reports a series of patients with Mirizzis syndrome (MS) who were managed at our institution over an 11-year (1994-2005) period. METHODS Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospitals radiology computer coding system. RESULTS 33 patients were identified with a median age of diagnosis of 70 (35-90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1-7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2). CONCLUSION Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.

Role of neoadjuvant chemotherapy in the treatment of multiple colorectal metastases to the liver (Br J Surg 2003; 90: 963-969).

Sir The authors conclude that neoadjuvant chemotherapy has survival advantages for bilobar CRC liver metastases, based on their retrospective series. This is unsupported by the data, pooled from two centres differing geographically and philosophically. This is exemplified by centre A adopting an approach to resectability post chemotherapy, and B who are aggressive from the outset. Clearly the Neo+ group is self-selected, based on a favourable response to neoadjuvant chemotherapy from a larger group of patients, excluding those who developed further disease. In the senior authors’ own published series only 5–16 per cent of patients with conventionally unresectable disease underwent resection after neoadjuvant chemotherapy. One cannot consider that patients in the Neo+ group were inoperable to start with, as the disease was comparable to the Neo− group that underwent resection. The data suggest a tendency towards greater blood loss, hospital stay, and postoperative morbidity (44 per cent versus 12 per cent) in the Neo+ group after second stage hepatectomy. Exclusion of the postoperative death in the Neo− group clearly shows no survival benefit with neoadjuvant chemotherapy (P > 0·06). It is well recognised that tumour distribution in bilobar disease does not affect survival and hepatic resection should be attempted regardless of the number of metastases, providing a complete resection with clear margins is expected. It is wholly inappropriate to advocate blanket neoadjuvant chemotherapy without a prospectively evaluated RCT, as it may deem unresponsive patients inoperable. S. Rahman, G. J. Toogood, P. J. Lodge and K. R. Prasad Hepatobiliary and Transplant Unit, St. James University Hospital, Leeds, UK DOI: 10.1002/bjs.4440 Randomized clinical trial comparing consultant-led or open access investigation for large bowel symptoms (Br J Surg 2003; 90: 941–947)