William Fawcett

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.

Severe Anaphylactic Reaction to Cisatracurium

A fit, 29-yr-old female patient (56 kg, ASA physical status I) was admitted for a diagnostic laparoscopy. She had no medical history of note, had no history of atopy or allergic reactions to drugs, and had never received a previous anesthetic. There was no family history of atopy. She was receiving no medication on admission. Diclofenac sodium 100 mg was given rectally 30 min before anesthesia. Full monitoring was established. She then received propofol 200 mg, lidocaine 20 mg, fentanyl 100 mg, midazolam 2 mg, and cisatracurium 10 mg IV. Her trachea was intubated and ventilated with a mixture of oxygen and nitrous oxide with isoflurane. At this stage, the electrocardiogram showed a sinus tachycardia of 145 bpm, and the pulse oximeter reading decreased from 96% to 67%. She was tracheally extubated and reintubated with the same tracheal tube, but there was no improvement in oxygen saturation. On auscultation, there was good air entry in both lungs with no signs of bronchospasm, and airway pressures did not exceed 30 cm H2O on manual ventilation. However, heart sounds were faint, and no carotid pulse was palpable. The patient appeared pale, and the capillary filling time was poor. The pulse oximeter and the noninvasive blood pressure monitoring were unrecordable. A diagnosis of anaphylactic shock was made. Cardiopulmonary resuscitation was started, and epinephrine 0.5 mg was given IV. Two 14-gauge cannulae and a central venous cannula were inserted. She received 3 L of crystalloid and 1 L of colloid. Another dose of epinephrine 0.5 mg was given IV. After approximately 20 min, a satisfactory carotid pulse was palpable, and the noninvasive blood pressure monitoring showed a blood pressure of 122/60 mm Hg. Hydrocortisone 200 mg IV was then given. One hour after the event, the patient was hemodynamically stable and began making good inspiratory efforts. The neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.5 mg. The surgery was canceled, and the patient made a full recovery with no neurological sequelae. EDTA blood samples were taken 0, 4, 9, and 24 h postreaction for plasma tryptase, and urine samples were taken at 4 and 24 h for methylhistamine. This showed very high levels of plasma tryptase and urinary methylhistamine (Tables 1 and 2). Epidermal skin prick testing was performed 4 wk later. A positive result was seen with cisatracurium at a 1:100 dilution. All of the other drugs tested gave negative responses down to a 1:10 dilution, with the exception of morphine, which gave a weak positive response at this dilution (Table 3). The patient was fully informed of the test results, and arrangements were made for her to receive a Medicalert bracelet. She returned 6 wk later for a laparoscopy under general anesthesia. Etomidate, fentanyl, and vecuronium were used, and the operation was uneventful.

Vocal fold palsy after use of the laryngeal mask airway

We report two cases of left vocal fold palsy following use of the laryngeal mask airway. In both cases anaesthesia was uneventful with a duration of about 60 minutes. It is proposed that high intra-cuff pressures induced during anaesthesia resulted in distension of the hypopharynx and subsequent neuropraxia of the motor branches of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve.

Recurrent laryngeal nerve palsy and the laryngeal mask airway

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Anesthesia for Colorectal Surgery

Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.

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.

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.