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The aim was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting and an intention to treat analysis of long-term survival between the two groups.This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019.In this study of 216 consecutive operable patients, 70 followed the fast-track pathway and 146 had pre-operative biliary drainage. All 70 patients in the FT group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was shorter in the FT group, (median 8 vs 43 days p 0.001 and 3 vs 36 days p 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p 0.001). Postoperative outcomes including complications, readmission and mortality rates were comparable in the two groups. There was no difference in survival.For a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage.

Objective The aim of the study was to determine the impact of age on curative management and outcomes of patients with pancreatic ductal adenocarcinoma. Methods Patients who underwent resection for pancreatic ductal adenocarcinoma at 2 units were retrospectively reviewed (between 2005 and 2017) and stratified by age (older patients ≥70 years). Regression analysis was used to explore factors impacting administration of adjuvant chemotherapy and survival. The Kaplan-Meier method was used to estimate overall survival (time from surgery to death). Statistical significance was set at P < 0.05. Results From 2005 to 2014, 222 patients were identified ( 0.05). Frailty was the commonest reason (36.8%) to decline chemotherapy in elderly patients. In patients receiving adjuvant chemotherapy, completion rates (P = 0.32) and overall survival (24 months vs 30 months, P = 0.50) were no different. Conclusions Elderly patients demonstrate similar outcomes to younger yet are less likely to commence chemotherapy because of frailty. Holistic preoperative assessment may improve selection for curative treatment.

Objective Patients with severe acute pancreatitis were excluded from major trials of human recombinant activated protein C (Xigris) because of concern about pancreatic haemorrhage although these individuals have an intense systemic inflammatory response that may benefit from treatment. The object of this study was to provide initial safety data evaluating Xigris in severe acute pancreatitis. Design Prospective clinical trial recruiting between November 2009 and October 2011. Patients received human recombinant activated protein C (Xigris) for 24 h by intravenous infusion (24 μg/kg/h) in addition to standard clinical care. A matched historical control group treated within the same hospital unit were used to compare outcomes. Of 166 consecutive admitted patients, 43 met the screening criteria for severe acute pancreatitis and 19 were recruited, all contributing to the analyses. Results Compared to historical controls, there were fewer bleeding events in the Xigris group although the finding did not reach significance (Xigris 0% vs. Control 21%, p = 0.13), similarly further intervention appeared less frequent (11% vs. 47%, p = 0.07) in the treatment group. Length of stay was shorter for patients receiving Xigris (19 vs. 41 days, p = 0.03) as was inotrope use (5% vs. 32%, p = 0.02); mortality and incidence of infections in both groups were similar. Biomarker protein C increased while IL-6 decreased following infusion. Conclusions A 24-hr infusion of Xigris appears safe when used in patients with severe acute pancreatitis. Trial registration Eudract Number 2007-003635-23.

Objectives Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity. This trial compared the effects of perioperative enteral immunonutrition (EIN) versus standard enteral nutrition (SEN) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer. Methods Thirty-seven patients were randomized (EIN, n = 17; SEN, n = 20) to receive feed for 14 days preoperatively and 7 days postoperatively. Mediators of systemic immunity (interleukin 1α, tumor necrosis factor α, lymphocytes subsets, and complement components) and of mucosal immunity in duodenal biopsies, nutritional markers and parameters were evaluated. Results The groups were comparable for demographics, the concentrations of mediators of systemic and mucosal immunity at time of recruitment, and for the duration and amount of feed received. Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor α and total hemolytic complement. Enteral immunonutrition-fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients. Conclusions The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.

Objectives. This study is a questionnaire survey on the use of pharmacological agents to modify liver ischaemia-reperfusion (IR) injury in patients undergoing hepatectomy for colorectal liver metastases with the target population being those units participating in the LiverMetSurvey international registry. Methods. Members of LiverMetSurvey were sent an online questionnaire using SurveyMonkey comprising ten questions on the use of pharmacological agents to modulate hepatic IR injury in the perioperative period after hepatectomy. The questionnaire was sent to 446 clinicians registered with the LiverMetSurvey. There were 83 (19%) respondents. Results. Fifty-two (77% of 68 respondents to this question) never used pharmacological agents to modify liver IR injury during hepatectomy. Thirteen (19%) used pharmacological agents selectively. Three (4%) used these routinely. N-Acetylcysteine was the most widely used pharmacological agent with equal distribution of use around intraoperative and postoperative periods. Conclusions. This is believed to be the first survey on the use of pharmacological agents to modify liver IR injury. The target population is clinicians involved in liver resection. The results show that pharmacological modulation is used by only a minority of respondents to this questionnaire and that when this treatment is selected, N-acetylcysteine is the most frequently used.

Background Current guidelines recommend pharmacological prophylaxis for patients undergoing abdominal surgery for malignancy. Liver resection exposes patients to risk factors for venous thromboembolism, but there is a risk of bleeding. The aim of this study is to evaluate the evidence base supporting the use of pharmacological thromboprophylaxis in liver surgery. Methods An electronic search was carried out for studies reporting the incidence of VTE following liver resection comparing patients receiving pharmacological prophylaxis with those who did not. The search resulted in 990 unique citations. Following the application of strict eligibility criteria 5 studies comprise the final study population. Results Included studies report on 3675 patients undergoing liver resection between 1999 and 2013. 2256 patients received chemical thromboprophylaxis, 1412 had mechanical prophylaxis only and 7 received no prophylaxis. Meta-analysis revealed lower VTE rates in patients receiving chemical thromboprophylaxis (2.6%) compared to without prophylaxis (4.6%) (Dichotomous correlation test, odds ratio: 0.631 [95% Cl: 0.416–0.959], Fixed model, p = 0.030). Data regarding bleeding could not be pooled for meta-analysis, but chemical thromboprophylaxis was reported as safe in four studies. Conclusion This systematic review and meta-analysis of retrospective studies indicates that the use of perioperative chemical thromboprophylaxis reduces VTE incidence following liver surgery without an apparent increased risk of bleeding.

Colorectal cancer metastases occur predominantly in the liver, with extrahepatic sites being far less common and equally distributed in the lung, brain, skin, and bone. We report two cases of unusual bony metastases of colorectal cancer. A 55-year-old man underwent an abdominoperineal resection for a Dukes B carcinoma of the rectum, followed 17 months later by a right hemihepatectomy for metachronous liver metastases. He subsequently presented 11 months later with a solitary metastatic deposit in the mandible. Seven months after resection and reconstruction, he remained well and disease-free. A 67-year-old man underwent a right hemicolectomy and right hemihepatectomy for carcinoma of the cecum and synchronous liver metastases. He presented 16 months later with a lesion suspicious of metastases in his clavicle. He subsequently died 18 months after his original operation. The prolongation of survival after hepatic metastasectomy results in the presentation of metastases at sites not commonly seen in colorectal malignancy. Postoperative surveillance after apparently curative hepatectomy should be directed to the evaluation of any unusual new symptoms.

BACKGROUND Perihilar cholangiocarcinoma (PHCC) is a rare tumor with a poor prognosis. Outcomes may be optimized by centralization. Recent trends suggest further improvement by localization to transplant centers. This study examines outcomes from the management of PHCC in a nontransplant hepatopancreatobiliary center. METHODS Data were collected prospectively from patients undergoing treatment for PHCC from October 1999 to May 2011. Twenty-four patients underwent surgery. A further 54 patients had inoperable PHCC. Outcome data are reported. RESULTS Twenty-two of 24 patients required liver resection with histological R0 status in 12 (50%). In-hospital mortality occurred in two (8%). The mean survival of patients undergoing resection was 39 (95% CI: 16-61) months. The mean survival of nonresected patients was 5 (95% CI: 3-7) months (P

Background & Aims We investigated whether antioxidant therapy reduces pain and improves quality of life in patients with chronic pancreatitis. Methods We performed a double-blind, randomized, controlled trial that compared the effects of antioxidant therapy with placebo in 70 patients with chronic pancreatitis. Patients provided 1 month of baseline data and were followed for 6 months while receiving either antioxidant therapy (Antox version 1.2, Pharma Nord, Morpeth, UK) or matched placebo (2 tablets, 3 times/day). The primary analysis was baseline-adjusted change in pain score at 6 months, assessed by an 11-point numeric rating scale. Secondary analyses included alternative assessments of clinical and diary pain scores, scores on quality-of-life tests (the European Organization for Research and Treatment of Cancer [EORTC-QLQ-C30], Quality of Life Questionnaire-Pancreatic modification [QLQ-PAN28], European Quality of Life questionnaire [EuroQOL EQ-5D], and European Quality of Life questionnaire - Visual Analog Score [EQ-VAS]), levels of antioxidants, use of opiates, and adverse events. Analyses, reported by intention to treat, were prospectively defined by protocol. Results After 6 months, pain scores reported to the clinic were reduced by 1.97 from baseline in the placebo group and by 2.33 in the antioxidant group but were similar between groups (−0.36; 95% confidence interval [CI], −1.44 to 0.72; P = .509). Average daily pain scores from diaries were also similar (3.05 for the placebo group and 2.93 for the antioxidant group, a difference of 0.11; 95% CI, 1.05–0.82; P = .808). Measures of quality of life were similar between groups, as was opiate use and number of hospital admissions and outpatient visits. Blood levels of vitamin C and E, β-carotene, and selenium were increased significantly in the antioxidant group. Conclusions Administration of antioxidants to patients with painful chronic pancreatitis of predominantly alcoholic origin does not reduce pain or improve quality of life, despite causing a sustained increase in blood levels of antioxidants; ClinicalTrials.gov number, ISRCTN-21047731.