O. J. Garden

Moderate hypothermia prevents cerebral hyperemia and increase in intracranial pressure in patients undergoing liver transplantation for acute liver failure

Background. During orthotopic liver transplantation (OLT) for acute liver failure (ALF), some patients develop acute increases in intracranial pressure (ICP). The authors tested the hypothesis that increases in ICP during OLT for ALF can be prevented by moderate hypothermia. Methods. Sixteen patients with ALF undergoing OLT were studied. Depending on the measured ICP before OLT, the patients were divided into three groups as follows: group I (n=6), did not require treatment for increased ICP (ICP <15 mm Hg); group II (n=5), had episodes of increased ICP that were controlled by conventional treatment (group I and group II patients were maintained normothermic during OLT); and group III (n=5), had uncontrolled increased ICP before OLT for which they had been cooled and underwent OLT with the median core temperature of 33.4°C (92.1°F) (range, 31.9°–33.8°C [89.4°–92.8°F]) Results. There was a significant increase in ICP during the dissection and reperfusion phases in the patients in groups I and II (P =0.004 and P =0.006, respectively). Patients in group III had no significant increase in ICP during the OLT. The increase in ICP in groups I and II was associated with an increase in cerebral blood flow, which was not observed in group III. The increase in ICP was corrected during the anhepatic phase of the operation. There was no difference in the requirement of transfusions or incidence of postoperative infection between the groups. Conclusions. Moderate hypothermia is safe and successfully prevents increases in ICP during OLT for ALF.

Early specialist repair of biliary injury

Considerable debate surrounds the timing of repair of injury to the common bile duct following cholecystectomy. In the absence of sepsis or significant peritoneal soiling, repair within the first week may be optimal. This study compared the outcome of early (within the first 2 weeks) and delayed (between 2 weeks and 6 months) repair.

Liver Resection and Transplantation in the Management of Iatrogenic Biliary Injury

BackgroundBiliary injury during cholecystectomy can be managed successfully by biliary reconstruction in the majority of patients; however, a proportion of patients may require hepatic resection or even liver transplantation.MethodsData on all patients referred with biliary injuries were recorded prospectively. The details of patients who required hepatic resection or transplantation were analyzed and compared to those patients managed with biliary reconstruction alone.ResultsFrom November 1984 until November 2003 there were 119 patients referred with Strasberg grade E injuries to the biliary tree, 14 of whom (9 women, 5 men) required hepatic resection or transplantation. The median age of these 14 patients was 48 (range: 30–81) years. Nine patients were considered for hepatic resection, and of these six underwent right hepatectomy, two had a left lateral sectionectomy, and one patient was deemed unfit for surgery and underwent metal stenting of the right hepatic duct. All patients are alive and remain well. Five patients developed hepatic failure and were considered for liver transplantation. Two patients who were unfit for transplantation died, and another died while on the waiting list for transplantation. The remaining two patients underwent liver transplantation, and one of them died from overwhelming sepsis. Concomitant vascular injury was demonstrated in 8 of the 14 patients (57%), and in 3 of the 4 (75%) patients that died.ConclusionsHepatic atrophy or sepsis after biliary injury can be managed successfully with hepatic resection. Liver transplantation is required occasionally for patients with secondary biliary cirrhosis, but is rarely successful for early hepatic failure following iatrogenic biliary injury.

An audit of the management of patients with acute pancreatitis against national standards of practice

The aim of this study was to audit the management of patients with acute pancreatitis against the standards of practice in the British Society of Gastroenterology guidelines.

Presentation, treatment and outcome in patients with ampullary tumours†

Ampullary tumours are relatively rare, and few large single‐centre reports provide information on their treatment and outcome. The aim of this study was to analyse outcome and determine predictors of survival for patients with ampullary tumours treated in a specialist centre.

The Selective Use of Magnetic Resonance Cholangiopancreatography in the Imaging of the Axial Biliary Tree in Patients with Acute Gallstone Pancreatitis

Background: Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit. Methods: Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis. Results: 249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18–204) vs. MRCP 39 mmol/l (24–180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3–14) vs. ERCP 9 days (range: 4–20), p < 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p < 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94). Conclusions: MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital stay.

Tryptophan catabolites in mesenteric lymph may contribute to pancreatitis-associated organ failure

Multiple organ failure (MOF) is the key determinant of mortality in acute pancreatitis (AP). Mesenteric lymph cytotoxicity contributes to organ failure in experimental models of systemic inflammation. The aim of this study was to evaluate the mesenteric lymph pathway and the lymph injury proteome in experimental AP‐associated MOF, and to test the hypothesis that immunoregulatory tryptophan catabolites contribute to mesenteric lymph cytotoxicity.

Validation of a prognostic nomogram in patients undergoing resection for pancreatic ductal adenocarcinoma in a UK tertiary referral centre

INTRODUCTIONnSurvival following resection for pancreatic ductal adenocarcinoma (PDAC) remains poor. The aim of this study was to validate a survival nomogram designed at the Memorial Sloan-Kettering Cancer Centre (MSKCC) in a UK tertiary referral centre.nnnMETHODSnPatients who underwent resection for PDAC between 1995 and 2005 were analysed retrospectively. Standard prognostic factors and nomogram-specific data were collected. Continuous data are presented as median (inter-quartile range).nnnRESULTSnSixty-three patients were analysed. The median survival was 326 (209-680) days. On univariate analysis lymph node status (node +ve 297 (194-471) days versus node -ve 367 (308-1060) days, p=0.005) and posterior margin involvement (margin +ve 210 (146-443) days versus margin -ve 355 (265-835) days, p=0.024) were predictors of a poor survival. Only lymph node positivity was significant on multivariate analysis (p=0.006). The median nomogram score was 217 (198-236). A nomogram score of 113-217 predicted a median survival of 367 (295-847) days compared to 265 (157-443) days for a score of 218-269, p=0.012.nnnCONCLUSIONnIncreasing nomogram score was associated with poorer survival. However the accuracy demonstrated by MSKCC could not be replicated in the current cohort of patients and may reflect differences in patient demographics, accuracy of pathological staging and differences in treatment regimens between the two centres.

Outcomes following a dedicated period of research during surgical training.

With recent ‘working-time-related changes to surgical training structure, the value of dedicated research during surgical training has been questioned. Online survey examining career and academic outcomes following a period of surgically related dedicated research at a Scottish University between 1972 and 2007. Of 58 individuals identified, contact details were available for 49 and 43 (88%) responded. Ninety-five percent (n = 41) of respondents continue to pursue a career in surgery and 41% (n = 17) are currently in academic positions. Ninety-one percent (n = 39) had published one or more first-author peer-reviewed articles directly related to their research, with 53% (n = 23) publishing three or more. Respondents with a clinical component to their research published significantly more papers than those with purely laboratory-based research (P = 0.04). Eighty-one percent (n = 35) thought that research was necessary for career progression, but only 42% (n = 18) felt research should be integral to training. In conclusion, the majority of surgical trainees completing a dedicated research period, published papers and continued to pursue a surgical career with a research interest. A period of dedicated research was thought necessary for career progression, but few thought dedicated research should be integral to surgical training.

Long-term survival following delayed presentation and resection of colorectal liver metastases (Br J Surg 2011: 98: 1309-1317).

Background: Long-term survival from metastatic colorectal cancer is partly dependent on favourable tumour biology. Large case series have shown improved survival following hepatectomy for colorectal liver metastases (CRLM) in patients diagnosed with metastases more than 12 months after index colorectal surgery (metachronous), compared with those with synchronous metastases. This study investigated whether delayed hepatic resection for CRLM affects long-term survival. Methods: Consecutive patients undergoing hepatic resection for CRLM in a single centre (1987–2007) were grouped according to the timing of hepatectomy relative to index bowel surgery: less than 12 months (synchronous; group 1), 12–36 months (group 2) and more than 36 months (group 3). Cancer-specific survival was calculated using Kaplan–Meier analysis. Results: There were 577 patients (48·0 per cent) in group 1, 467 (38·9 per cent) in group 2 and 158 (13·1 per cent) in group 3. The overall 5-year cancer-specific survival rate after liver surgery was 42·3 per cent, with no difference between groups. However, when measured from the time of primary colorectal surgery, group 3 showed a survival advantage at both 5 and 10 years (94·1 and 47·6 per cent respectively) compared with groups 1 (46·3 and 24·9 per cent) and 2 (57·1 and 35·0 per cent) (P = 0·003). Survival graphs showed a steeper negative gradient from 5 to 10 years for group 3 compared with groups 1 and 2 (−0·80 versus −0·34 and −0·37), indicating an accelerated mortality rate. Conclusion: Patients undergoing delayed liver resection for CRLM have a survival advantage that is lost during long-term follow-up.