Nariman D. Karanjia

Randomized clinical trial on enhanced recovery versus standard care following open liver resection

Enhanced recovery programmes (ERPs) have been shown to reduce length of hospital stay (LOS) and complications in colorectal surgery. Whether ERPs have the same benefits in open liver resection surgery is unclear, and randomized clinical trials are lacking.

Reduced adhesion formation following laparoscopic versus open colorectal surgery

Adhesion formation is common after abdominal surgery. This study aimed to compare the extent of adhesion formation following laparoscopic and open colorectal surgery.

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.

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.

Jejunal perforation in gallstone ileus – a case series

AbstractIntroductionGallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.Case presentationsCase 1 A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected. Case 2 A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.ConclusionGallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.

'Close Shave' in liver resection for colorectal liver metastases

INTRODUCTION The optimal size of clear liver resection margin width in patients with colorectal liver metastases (CRLM) remains controversial. The aim of this study was to investigate the effects of margin width on long-term survival after liver resection for CRLM with a policy of standard neo-adjuvant chemotherapy. METHODS Consecutive patients (n=238) who underwent liver resection for CRLM were included over a ten-year period. All patients with synchronous or early (<2 years) metachronous tumours were treated with neo-adjuvant chemotherapy. Data were recorded prospectively. RESULTS Overall survival of the cohort at 1, 3 and 5 years were 90.3%, 68.1% and 56.1% respectively. The incidence of cancer involved resection margins (CIRM) was 5.8%. Patients with macroscopically involved resection margins had a poorer overall survival than those with microscopically involved margins (p=0.04). Involved resection margins had a poorer overall survival (p=0.002) than patients with clear margins. Width of clear resection margin did not affect long-term survival. CONCLUSION CIRM independently predicts poor outcome in patients with CRLM. Clear margin width does not affect survival. A standard policy of neo-adjuvant chemotherapy may be associated with a low incidence of CIRM and improved long-term outcome of sub-centimetre margin widths, resembling those with >1cm resection margins.

Solitary Liver Metastasis of Chromophobe Renal Cell Carcinoma 20 Years After Nephrectomy Treated by Hepatic Resection

A small proportion of patients with metastatic renal cell carcinoma have operable liver metastases, as there is often multiple dissemination within the liver and to other organs. We present a case of a solitary liver metastasis found incidentally 20 years after radical nephrectomy for a chromophobe renal cell carcinoma. The patient underwent a liver resection with tumor-free margins and recovered uneventfully. Time will tell if this was oncologically successful.

The measurement of liver resection margins

BACKGROUND All tissue shrinks to some degree when placed in formalin fixative solution. The degree of shrinkage of liver tissue has particular relevance to the measurement of resection margins, as the current recommendation is that the surgeon should aim to achieve a resection margin of at least 1 cm. We were unable to find any published data concerning shrinkage of liver tissue in formalin. The aim of this study was therefore to quantify the shrinkage of liver specimens in the fixation process. METHODS Distances of 10, 30 and 50 mm were measured and marked on 18 fresh liver specimens. The specimens were then fixed in 10% formalin solution for 24 h, and the distances were re-measured to assess shrinkage. RESULTS The observed shrinkage at all three distances was <10% after 24 h in formalin. The degree of shrinkage was statistically significant. CONCLUSION Although the degree of shrinkage is small, it may be important when considering resection margins of the order of 1 cm and should therefore be taken into account.

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.