Comparison of risk-scoring systems in the prediction of outcome after liver resection.

BACKGROUND: Risk prediction techniques commonly used in liver surgery include the American Society of Anesthesiologists (ASA) grading, Charlson Comorbidity Index (CCI) and cardiopulmonary exercise tests (CPET). This study compares the utility of these techniques along with the number of segments resected as predictive tools in liver surgery. METHODS: A review of a unit database of patients undergoing liver resection between February 2008 and January 2015 was undertaken. Patient demographics, ASA, CCI and CPET variables were recorded along with resection size. Clavien-Dindo grade III-V complications were used as a composite outcome in analyses. Association between predictive variables and outcome was assessed by univariate and multivariate techniques. RESULTS: One hundred and seventy-two resections in 168 patients were identified. Grade III-V complications occurred after 42 (24.4%) liver resections. In univariate analysis of CPET variables, ventilatory equivalents for CO2 (VEqCO2) was associated with outcome. CCI score, but not ASA grade, was also associated with outcome. In multivariate analysis, the odds ratio of developing grade III-V complications for incremental increases in VEqCO2, CCI and number of liver segments resected were 1.09, 1.49 and 2.94, respectively. CONCLUSIONS: Of the techniques evaluated, resection size provides the simplest and most discriminating predictor of significant complications following liver surgery.

Evaluation of the introduction of a standardised protocol for the staging and follow-up of colorectal cancer on resection rates for liver metastases.

INTRODUCTION: In 2004, an audit in our unit demonstrated wide variation in liver resection rates for colorectal cancer (CRC) metastases within the cancer network. Subsequently, a network-wide CT-based follow-up and referral policy was introduced for all patients. A second audit was performed to assess the impact of the guidelines on liver resection rates. SUBJECTS AND METHODS: Analysis of prospective liver resection database between 1997 and 2004 and after the introduction of standardised guidelines between January 2005 and April 2008. RESULTS: A total of 362 patients underwent liver resection for CRC metastases between 1997 and 2008, 237 prior to the introduction of the referral guidelines and 125 after. Liver resection rates according to referring hospital varied from 0.92 to 2.32 per 100,000 population before guidelines were introduced. After 2005, resection rates from the four district hospitals standardised (1.68-1.84 per 100,000 population), but the central unit rate (Sheffield) remained significantly higher (2.67 per 100,000 population). No significant difference in 1-year disease-free survival between patients from Sheffield and the out-lying hospitals was found (P = 0.553). CONCLUSIONS: Introduction of a referral protocol standardised resection rates from the four district hospitals, but these remain lower compared to the specialist centre. The wide-spread adoption of a policy to discuss all patients with liver metastases at an advanced disease multidisciplinary team meeting, in the presence of hepatobiliary specialists, may further increase resection rates across the UK.

Defining ductal anatomy using CT cholangiography in a patient with gallbladder duplication.

Duplication of the gallbladder is a rare congenital abnormality. Pre-operative diagnosis is challenging and, with the almost universal use of laparoscopic cholecystectomy, the scope for missing the second intrahepatic gallbladder is increased. Here we report the use of CT cholangiography to define ductal anatomy successfully in a patient with gallbladder duplication.

Introduction of a day-case laparoscopic cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care providers.

INTRODUCTION: The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK. PATIENTS AND METHODS: Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation. RESULTS: A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the readmission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days. CONCLUSIONS: Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.

Anal ulceration associated with Nicorandil: case series and review of the literature.

BACKGROUND: Use of Nicorandil in the treatment of ischaemic heart disease has been associated with oral, ileal and more recently anal ulceration. We report a series of six cases of peri-anal ulceration in patients on nicorandil therapy, their response to withdrawal of the drug and review the literature. METHODOLOGY: Systematic case note review of all patients with anal ulceration presenting to a single colorectal unit. Including detailed medical and drug history, morphological and histological appearances of the peri-anal ulcer after biopsy. Nicorandil therapy stopped in conjunction with physician and the progress of the ulcer monitored. Photographs taken before and after cessation of Nicorandil after informed consent. A literature search on Nicorandil combined with the key words: anal, peri-anal, ulceration and adverse drug effects was performed using the Cochrane Library Medline (January 1966 to June 2005) and Embase (January 1974 to June, 2005). RESULTS: Six patients were identified from our hospital records. Histological examination of all ulcers revealed nonspecific chronic inflammation. Five patients demonstrated healing of ulceration within six weeks of withdrawal of Nicorandil, the remaining patient had circumferential involvement of the anal canal and has not improved at 3-month review. One patient was recommenced on Nicorandil after healing due to refractory angina and ulceration recurred. CONCLUSIONS: We believe ulceration due to Nicorandil remains widely under diagnosed and the mechanism of ulceration is unclear. Despite diversion colostomy one of our patients continued with peri-anal ulceration, which may suggest a systemic mechanism rather than local irritation. Biopsy of these lesions is essential to exclude neoplastic process and inflammatory bowel disease.