N. Quiney

A 10-year study of outcome following hepatic resection for colorectal liver metastases - The effect of evaluation in a multidisciplinary team setting.

AIMS Colorectal carcinoma is the second most common cause of cancer death in the western world and nearly 50% of patients develop liver metastases. Many cancers are managed via a multidisciplinary team process. This study compares the long term outcome of patients with metastatic colorectal cancer referred via a multidisciplinary team including a liver surgeon (MDT) with those referred directly to a specialist hepatobiliary unit. PATIENTS AND METHOD This is a prospective study of 331 consecutive referrals made to a specialist hepatobiliary unit over ten years out of which 108 patients were referred via a colorectal MDT which included a liver surgeon and 223 were directly referred via colorectal MDTs without a liver surgeon. Pre-operative assessment and management were standardised and short and long term data were recorded. RESULTS Patients referred via the MDT had 1-, 3- and 5-year survival rates of 89.6%, 67.5% and 49.9% respectively and 1-, 3- and 5-year disease-free survival of 65.4%, 31% and 27.2% respectively. Patients referred directly had 1-, 3- and 5-year survival rates of 90.3%, 54.1% and 43.3% respectively and 1-, 3- and 5-year disease-free survival rates of 70.3%, 37.6% and 27.9% respectively. The difference in overall survival was significant (P=0.0001), although the difference in disease-free survival was not (P=0.21). CONCLUSION Assessing, managing and referring patients with metastatic colorectal cancer via a multidisciplinary team including a liver surgeon is associated with improved overall survival.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence‐based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal‐directed fluid therapy and postoperative intensive care.

A comparison of right and extended right hepatectomy with all other hepatic resections for colorectal liver metastases: A ten-year study

AIMS Colorectal liver metastases are treated by a combination of adjuvant chemotherapy followed by liver resection. In this study we compared all major right-sided resections with left or parenchymal sparing resections. METHODS Consecutive patients (n=283) who had successful hepatic resections for colorectal metastases from September 1996 to November 2006 were prospectively studied. Early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardised for all. RESULTS The 1-, 3- and 5-year overall survival rates in the RH group were 84.1%, 54.3% and 38.9%, respectively. The 1-, 3- and 5-year overall survival rates in the AOLR group were 95.4%, 65.9% and 53.3%, respectively. The difference was statistically significant (p=0.03). The 1-, 3- and 5-year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5%, respectively and 68.4%, 34.91% and 34.91%, respectively in the AOLR group (p=0.46). Operative mortality was 3.9% in the RH group and 0.7% in the AOLR group (p=0.04). Morbidity was 31.3% in the RH group and 18% in the AOLR group. CONCLUSION Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases ― A ten year study

BACKGROUND Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery. METHODS 283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors. RESULTS Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively. CONCLUSIONS Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Enhanced recovery after surgery (ERAS) has been adopted by many centres and across whole healthcare systems. The results have shown significant reductions in length of stay and postoperative complications. However, there has been very little change in these factors and mortality in emergency surgery. Can we learn from principles of ERAS for emergency abdominal surgery?

Early postoperative outcomes following hepatic resection for benign liver disease in 79 consecutive patients

BACKGROUND Liver resection is an accepted treatment modality for malignant disease of the liver. However, because of its potential morbidity and mortality, the practice of liver resection in benign disease is more controversial. This study was designed to assess the early outcomes of 79 consecutive liver resections for benign disease over a 12-year period and compare these with early outcomes of 390 consecutive liver resections for metastatic colorectal cancer (MCRC) during the same period. METHODS Consecutive liver resections were carried out in a single hepatopancreatobiliary (HPB) centre between 1996 and 2008. Patient demographics and early outcomes were recorded. Statistical analyses were performed using spss (Version 15). P < 0.05 was considered to be significant. RESULTS There was no difference in median age between the benign group vs. the MCRC group (P = 0.181). However, there was a significant trend towards a lower ASA grade in the benign group (P < 0.001). There was no difference in median blood loss (P = 0.139) or hospital stay (P = 0.262). Morbidity rates were 8.9% in the benign group and 20.5% in the MCRC group (P = 0.002). The rate of serious complications was 1.3% in the benign group compared with 4.4% in the MCRC group (P = 0.041). There were no postoperative deaths in the benign group and eight (2%) in the MCRC group (P = 0.004). CONCLUSIONS Liver resection for benign liver tumours can be undertaken with a mortality rate approaching zero and minimal morbidity in specialist HPB units.

Liver resection for colorectal cancer metastases involving the caudate lobe

Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer‐involved resection margins of over 50 per cent being reported following caudate lobe resection.

Anaphylaxis to dye during breast surgery

Dr Robinson’s letter highlighting the potential adverse reactions associated with Patent Blue V (Guerbet, Cedex, France) [1] is a useful reminder to anaesthetists of an adverse drug reaction that they may not have administered but will be expected to manage. The use of Patent Blue V dye is becoming more widespread since the publication of the ALMANAC trial [2]. We have been using Patent Blue V dye for almost 10 years and have managed many of the complications of its use [3, 4]. Over 3000 patients have been exposed to this drug and we have found 30 patients to date (approximately 1%) who have experienced severe anaphylaxis with cardiovascular collapse; this is similar to the 0.86% incidence from the ALMANAC and NEW START datasets [5]. The incidence of anaphylactic reactions during anaesthesia is estimated at between 1 in 3500 and 1 in 13000 [6]; with neuromuscular blocking drugs responsible for roughly 60% of reactions, followed by exposure to latex and antibiotics at around 15% each [7]. Our 1% rate of reaction therefore potentially makes Patent Blue V the most common drug causing severe anaphylaxis in the operating theatre environment. We have previously described a number of adverse effects [3, 4] including extreme pallor and the occurrence of large blue cutaneous wheals that may be a cause of concern, particularly to recovery nurses. However, it is the severe, life threatening cardiovascular collapse that we would particularly like to highlight. Whilst most anaphylactic or anaphylactoid reactions to anaesthetic drugs usually occur immediately after intravenous administration, we would stress that most reactions to Patent Blue V (which is administered subcutaneously or intra dermally by the surgeon) do not occur so quickly. Our experience is to find progressively severe hypotension occurring 20– 30 min after Patent Blue V injection. This delayed onset has on occasion led to significant delay in the correct diagnosis being made. Once the diagnosis has been made, intravenous adrenaline 1:10 000 is very effective at supporting the circulation. We have also found that the early administration of high-dose intravenous steroids (we use 1g methylprednisolone) is effective at reversing the cardiovascular collapse within 20 to 30 min of administration. Finally, although we have seen cutaneous blue wheals and cardiovascular collapse either in isolation or together, we have not seen any respiratory complications such as bronchospasm. In our experience, we have only ever seen these reactions following cutaneous injection, and interestingly never following the intra dermal injections for melanoma sentinel lymph node biopsy. We would be interested to hear whether other anaesthetists have had similar experiences when using this dye. N. Quiney C. Jones M. Kissin Royal Surrey County Hospital NHS Foundation Trust Guildford, U.K. Email: drchrisnjones@yahoo.co.uk

Sildenafil in Acute Pulmonary Embolism: Case Report and Review of Literature:

We discuss the use of sildenafil in a patient who sustained a massive pulmonary embolism (PE). She remained haemodynamically unstable after thrombolysis, and needed large doses of inotropic support. She was treated with oral sildenafil at a dose of 75 mg three times a day which enabled weaning from inotropic support and clinical improvement.

Epidural anaesthesia and analgesia for liver resection.

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