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BACKGROUND Approximately one-fifth of patients with colorectal cancer present with hepatic metastases. There are limited prospective data on the outcomes of synchronous combined liver and bowel surgery and liver-first or bowel-first routes where contemporary chemo(radio)therapy is integrated into management. METHODS Between 1 April 2014 and 31 March 2017, 125 patients with colorectal cancer and synchronous liver metastases were recruited. Data are reported on pathway-specific outcomes, including perioperative complications, treatment completion, and overall and disease-free survival. The study was registered with ClinicalTrials.gov (NCT02456285). RESULTS There was no difference in age, body mass index, or Charlson score between surgical groups. Neoadjuvant chemotherapy was used in 50 (40%) patients for a mean duration of 4.6 months (standard deviation [SD] 5.4), and mean time from completion of chemotherapy to surgery was 2.6 months (SD 1.9). Complications were similar between patients completing the synchronous and staged pathways (p = 0.66). Mean total inpatient stay was 16.5 days (SD 8.1) for staged surgery compared with 16.8 days (SD 10.3) for the synchronous group (t-test; p = 0.91). There was no difference in time to treatment completion between pathways. Thirty six (35%) patients were disease-free at 12 months, with no significant difference between groups (Chi-square, p = 0.448). Quality of life was similar in all surgical groups. CONCLUSIONS Perioperative complications and oncological and healthcare occupancy outcomes are equivalent between patients completing staged and synchronous pathways for the management of patients with colorectal cancer and synchronous liver metastases. Future studies should focus on optimizing the criteria for pathway selection, incorporation of cancer genomics data, and patient (user) preferences.

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.

Background: Index admission laparoscopic cholecystectomy is the standard of care for patients admitted to hospital with symptomatic acute cholecystitis. The same standard applies to patients suffering with mild acute biliary pancreatitis. Operating theatre capacity can be a significant constraint to same admission surgery. This study assesses the impact of dedicated theatre capacity provided by a specialist surgical team on rates of index admission cholecystectomy.Methods: This clinical cohort study compares the management of patients with symptomatic gallstone disease admitted to a tertiary care university teaching hospital over two equal but chronologically separate time periods. The periods were before and after service reconfiguration including a specialist HPB service with dedicated operating theatre time allocation.Results: There was a significant difference in the number of admissions over the two time periods with a greater proportion of patients having index admission surgery in the second time period with correspondingly fewer having more than one admission during this latter time period. In the second time period 43% of patients underwent index admission cholecystectomy compared to 23% in the first (P < 0.001). The duration of surgery was shorter for patients undergoing surgery during the second time period [135 (102–178) min in the first period and in the second period 106 (89–145) min] (P = 0.02).Discussion: This paper shows that the concentration of theatre resources and surgical expertise into regular theatre access for patients undergoing urgent laparoscopic cholecystectomy is an effective and safe model for dealing with acute biliary disease.

The aim of the study was to evaluate any social, occupational and physical factors, which may influence the occurence or cause of a primary inguinal hernia in two European countries. A questionnaire was completed by all the respondents in the setting of an out-patient clinic prospectively at the time of initial presentation and the data were collected on a secure database. All responses for each question were explored via appropriate descriptive statistics. Statistical comparisons were made using Fisher’s exact test where appropriate. 537 adults completed the questionnaire and had their data analysed. Comparisons between those that presented with a primary complaint of either ‘bulge/swelling’ or ‘discomfort/pain’ found no differences in occupation, age or any other demographic data. Equal proportions of patients who described a single strenuous event presented with a bulge/swelling or discomfort/pain. The reporting of a causative single strenuous event was not significantly influenced by occupation, lifestyle or amount of activity carried out nor was there any significant influence upon when a hernia presented after the suspected strenuous event, although the majority reported a lump within 1 week. This study cannot at present support the belief that a single strenuous event will be the sole cause for the development of a primary inguinal hernia.

Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery.Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures.Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality.Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures.

BackgroundSportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.MethodsA randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.ResultsA total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).ConclusionTotally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

Minimally invasive incisional hernia repair has been established as a safe and efficient surgical option in most centres worldwide. Laparoscopic technique includes the placement of an intraperitoneal onlay mesh with fixation achieved using spiral tacks or sutures. An additional step is the closure of the fascial defect depending upon its size. Key outcomes in the evaluation of ventral abdominal hernia surgery include postoperative pain, the presence of infection, seroma formation and hernia recurrence. TACKoMESH is a randomised controlled trial that will provide important information on the laparoscopic repair of an incisional hernia; 1) with fascial closure, 2) with an IPOM mesh and 3) comparing the use of an articulating mesh-fixation device that deploys absorbable tacks with a straight-arm mesh-fixation device that deploys non-absorbable tacks. A prospective, single-centre, double-blinded randomised trial, TACKoMESH, will establish whether the use of absorbable compared to non-absorbable tacks in adult patients undergoing elective incisional hernia repair produces a lower rate of pain both immediately and long-term. Eligible and consenting patients will be randomized to surgery with one of two tack-fixation devices and followed up for a minimum one year. Secondary outcomes to be explored include wound infection, seroma formation, hernia recurrence, length of postoperative hospital stay, reoperation rate, operation time, health related quality of life and time to return to normal daily activity. With ongoing debate around the best management of incisional hernia, continued trials that will add substance are both necessary and important. Laparoscopic techniques have become established in reducing hospital stay and rates of infection and report improvement in some patient centered outcomes whilst achieving similarly low rates of recurrence as open surgical techniques. The laparoscopic method with tack fixation has developed a reputation for its tendency to cause post-operative pain. Novel additions to technique, such as intraoperative-sutured closure of a fascial defect, and developments in surgical technology, such as the evolution of composite mesh design and mesh-fixation devices, have brought about new considerations for patient and surgeon. This study will evaluate the efficacy of several new technical considerations in the setting of elective laparoscopic incisional hernia repair. Name of registry - ClinicalTrials.gov Registration number: NCT03434301 . Retrospectively registered on 15th February 2018.

Introduction: This study looks at the outcome of 352 patients that underwent the “Manchester groin repair” in the period from 2007 to 2016. The effect of laterality on chronic groin pain and the reduction of pain scores post-surgery are evaluated as well as the rate of hernia recurrence for the inguinal hernia repairs.Methods: The “Manchester groin repair” is a modification of a laparoscopic totally extra-peritoneal approach with fibrin sealant mesh fixation. Data were collected prospectively. In addition to demographic data and the European Hernia Society classification grading of each hernia, pain scores were assessed prior to surgery and at 4–6 weeks post-operatively using a ten-point visual analog pain scale. Data were collected on a bespoke database and differences between time-points analyzed by non-parametric Wilcoxon signed rank tests with Kruskal-Wallis rank sum test for three-group comparisons. Significance was at the P < 0.05 level. The study was undertaken as an institutional audit.Results: Three hundred and fifty two patients underwent TEP repair as per the “Manchester Groin Repair” modification during the period of interest with a median follow-up period of 109.5 (IQR 57.0–318.5) weeks. Of these 274 (77.8%) were for the repair of true hernias and 78 (22.2%) were for inguinal disruptions.All inguinal hernia repairs patients were evaluated (254 m, 20 f); median [interquartile range] age 50 (39–65) years. There were 75 right inguinal hernias (27.4%), 39 Left inguinal hernias (14.2%), and 160 bilateral inguinal hernias (58.4%), giving a total of 434 hernia repairs. During follow-up there were 6 recurrences (1.4%).Of the 274 patients evaluated, 145 (52.9%) had both pre and post-operative pain scores available. Median pre-operative pain score was 5 [IQR 4–7]. Median post-operative pain score was 1 [IQR 1–2]. This difference was significant (P < 0.001). Pre-operative pain scores were higher for those with a bilateral hernia (median 6 vs. 5 and 4, respectively; P = 0.005), but there was no difference in post-operative scores (P = 0.347). One patient (0.3%) presented with chronic groin pain (pain after 3 months).Conclusion: This study demonstrates that the “Manchester groin repair” provides an excellent repair with a low rate of recurrence and low incidence of chronic pain. Longer-term evaluation and larger patient series will add to the understanding of the role of this procedure in groin hernia repair.

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.

Aims: To ascertain any predictors of potential food poisoning pathogens and development of post-infective irritable bowel syndrome (IBS) in UK travellers. An analysis was undertaken on prospectively collected data on 527 patients reporting symptoms of suspected food poisoning between June 2012 and June 2015. Main outcome measures: Positive stool sample indicative of food poisoning pathogens and diagnosis of post-infective IBS. Results: Data on 527 patients were examined. The large majority of patients did not provide a stool sample on return from holiday ( n = 430, 81.6%) as few visited a Doctor locally or in the UK. Only 18 patients (18.6%, 95% confidence interval [CI] 11.4–27.7) who provided a stool sample were positive for microbiological food poisoning pathogens. Univariate analysis indicated a significant relationship between a positive stool sample and whether the individual sought any medical assistance at the resort (odds ratio [OR] 0.24, 95% CI 0.08–0.70) and whether they took any treatment (including self-medicated), (OR 0.21, 95% CI 0.06–0.67). Of the 527 patients only 30 (5.7%, 95% CI 3.9–8.1) experienced post-infective IBS. Univariate regression indicated a significant relationship between experiencing Per Rectal (PR) bleeding and a diagnosis of post-infective IBS (OR 3.64, 95% CI 1.00–10.49). Univariate regression also indicated an increase in the risk of developing post-infective IBS with increasing duration of symptoms (OR 1.04, 95% CI 1.02–1.05). No significant relationship was found between a positive stool sample and developing post-infective IBS ( P = 0.307). Conclusions: Very few patients provide a stool sample after experiencing holiday sickness abroad. Of those that do, only a small proportion have a positive stool sample indicative of a food poisoning microorganism. Around 6% of individuals were diagnosed with post-infective IBS. Those individuals with PR bleeding and symptoms persisting for longer durations were significantly more at risk of developing post-infective IBS, whilst medical aid and treatment abroad was found to reduce the odds of a positive stool sample.

Background The aim of this study was to conduct a comprehensive systematic review comparing tissue glue (TG) against tacks/staples for mesh fixation in laparoscopic (totally extra-peritoneal and trans-abdominal pre-peritoneal) groin hernia repair with the incidence of post-operative chronic pain as the primary outcome measure.

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.

To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis.The last decade has witnessed major developments in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade.During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twenty-four (86%) were tertiary referral patients.The median APACHE II score on admission was 10.5 (5-26). Median logistic organ dysfunction score on admission was 3 (0-10). Median LODS score after surgery was 2 (0-8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths.Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

Objectives No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes. Data sources The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations. Results Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266). Conclusions Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

PURPOSE: The overall aim of this study was to develop a novel treatment for colorectal cancer based on the use of gene therapy. Genetic modification of T lymphocytes has been used to specifically target and kill tumor cell lines directly. To test the efficacy of this method with clinically relevant materials, this study investigated the potential of T lymphocytes derived from patients with advanced colorectal disease to target autologous primary tumor material. METHODS: T lymphocytes isolated preoperatively were modified genetically with recombinant retroviruses encoding CD3ζ-based chimeric immune receptors and were tested for functional activity against freshly isolated autologous tumor cells harvested from hepatic colorectal metastases. RESULTS: Patient-derived T cells were successfully transduced, and chimeric immune receptor expression was confirmed. Carcinoembryonic antigen expression on freshly isolated colorectal tumor cells was also demonstrated by molecular and immunohistochemical techniques. T cells expressing the anticarcinoembryonic antigen receptor were specifically activated by coculture with disaggregated or intact, diced tumor, whereas control non-carcinoembryonic antigen-targeted T-cell populations failed to activate. CONCLUSIONS: These results indicate that gene-targeted primary T lymphocytes depict specific functional activity against autologous colorectal tumor cells. This evidence indicates that chimeric immune receptor-expressing T cells may be able to circumvent the mechanisms used by tumor cells to avoid immune cell activity in vivo. This study emphasizes the potential of this approach as a therapy for carcinoembryonic antigen-expressing primary colorectal tumor and its metastases.

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 This article helps define the basic principles to diagnosis and manage one of the surgically correctable causes of the ‘painful groin’, which is commonly described as the sportsman’s groin. Discussion Often many surgeons will describe a single pathology for the sportsman’s groin such as a ‘hernia’ but often other coexisting etiologies may be present. Management relies on a multidisciplinary approach with a diagnosis initially made by a history of pain in the groin on exercise. Physiotherapy is the recommended first line treatment and is designed to concentrate on strengthening of the abdominal wall muscle and tendon groups around the groin area. Surgery does have a role in the sportsman’s groin but only once all conservative measures have been exhausted or if there is a clear identified pathology causing the groin symptoms such as posterior wall defect. Surgical principles for an inguinal disruption include either open or laparoscopic techniques reinforcing the inguinal canal with a mesh or suture repair followed by an active rehabilitation programme. Summary Once an accurate diagnosis has been achieved, contemporary guidance for inguinal disruption requires a multidisciplinary approach including a specially designed physiotherapy regime and possibly surgery.

Introduction The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG).\ud \ud Methods Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, UK on 11–12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly.\ud \ud Results The term ‘inguinal disruption’ (ID) was agreed as the preferred nomenclature with the term ‘Sportsman's hernia’ or ‘groin’ rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery.\ud \ud Conclusions ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

It is well recognised that for over three decades the aetiology, whether of hip or adductor, or groin related, and subsequent management, whether surgical or otherwise, of ‘sportsman's groin’ remains mainly controversial with the literature reporting mainly case series with a few randomised trials comparing differing treatment modalities and offering some anecdotal evidence. Eventually, in 2014, the world's first consensus statement was published, which has bravely attempted to define a condition where no true hernia exists but that is a perceived repetitive strain injury causing inguinal pain and/or disruption.1 The literature to date does report some prospective randomised data on open and laparoscopic surgical results, in comparison to active physiotherapy and other conservative measures, however, there are few high-quality studies, as reported by Serner et al , with surgery not figuring high on the treatment agenda.2–4 Some of these trials do, however, appear to demonstrate a distinct leaning towards surgical repair of the disrupted groin and associated chronic pain as the treatment of choice. The surgical repair technique used, though, has largely been an example on the expertise available in the respective units carrying out such repairs. This rationale is ever apparent, as no real study from any ‘sports groin’ unit has reported on more than one type of procedure being undertaken for inguinal-related groin pain or …

This review examines the types of material used in hernia repair over the last 50 years and the evolvement of surgical repair techniques. The rates of infection and recurrence associated with past and present materials are also evaluated. In conclusion, while newer materials are associated with fewer complications, close attention to surgical technique is the single most important factor in hernia repair.

Liver resection is generally accepted as the standard of care for patients with hepatic metastases from colorectal tumors in the absence of extrahepatic disease and for selected patients with primary hepatocellular carcinoma. However, in any given cohort of patients with hepatic tumors, most will be unsuitable for resection because of the extent of hepatic tumor burden, extrahepatic disease, or comorbidity. Treatment options in this setting include systemic modalities such as chemotherapy, regional interventions such as intra-arterial chemotherapy, and direct tumor ablation. Direct ablative treatments include intratumoral ethanol, laser, cryotherapy, and, more recently, radiofrequency ablation. Until the advent of radiofrequency, direct intratumoral ethanol and cryotherapy were perhaps the most widely used ablative approaches. Ethanol can be injected percutaneously and does not rely on costly equipment for delivery, and treatments can be repeated. Cryotherapy uses liquid nitrogen at )196 C delivered through a closed triplelumen probe and relies on cooling of liver tumors to at least )35 C. Tumor cell death occurs as a consequence of the formation of intracellular crystals during rapid freezing. Although widely used over the past decade, cryotherapy for liver tumors is not without problems. Freezing can lead to cracking or shearing of the liver parenchyma, andmajor hemorrhage results if these shearing injuries extend into major vessels. Late hemorrhage and intrahepatic abscesses related to biliary injury are also recognized complications. In addition to these local effects of cryotherapy, there are systemic side effects: the cytokine-mediated systemic illness associated with cryotherapy is characterized by fever, tachycardia, and tachypnea. This is known as the cryoshock syndrome and, in particular, can be associated with pleural effusion, diffuse lung injury, and acute renal tubular necrosis. The role of cryotherapy has become increasingly challenged since the advent of radiofrequency thermal ablation. This technique involves the passage of alternating high-frequency current (typically 10 kHz) through tissue. The molecular agitation caused by high-frequency energy leads to an increase in temperature in the tissue through which the current passes without causing muscle contraction or pain. If the field is applied between two equal-sized electrodes, the current flow per unit area of the electrode (current density) is similar in both electrodes. However, if one electrode is smaller, then, because the same total amount of current still has to flow, the current density is much higher at the smaller electrode, with a correspondingly higher temperature. Commercial availability of cooled-tip multiprobe electrodes equipped with probe-tip thermal sensors now permits the creation of a precise hepatic parenchymal ablation. In an important study, Scudamore et al. performed radiofrequency ablation of resectable liver tumors in 10 patients (7 patients with colorectal liver metastases) and then undertook liver resection in 9 of these individuals within 6 weeks of the ablation. On histological examination of the resected specimen by using nicotinamide adenine dinucleotide (NADH; a histochemical technique for demonstration of tissue oxidative enzyme activity), ablated tissue was recognized in all nine cases. The Received October 15, 2004; accepted December 2, 2004; published online March 3, 2005. Address correspondence and reprint requests to: Ajith K. Siriwardena, MD, FRCS; E-mail: ajith.siriwardena@cmmc.nhs.uk.

A sportsman’s groin has no accepted definition or consensus on treatment. The aim of this study was to assess current opinion among a large body of European surgeons using an online survey. An online questionnaire comprising 16 multiple-choice questions was sent by email to general surgeons in Europe. The survey was live from the 6th to 30th September 2011. In total 143 responses were received. One hundred and six respondents (74 %) expressed experience in managing this condition. The majority (91 %) managed

A 31-year-old man underwent a laparotomy for acute intestinal obstruction symptoms, which he had intermittently experienced for 14 years. The cause of the obstruction was due to a volvulus of the small bowel caused by a mesenteric lipoma. This is a rare finding, which is ideally diagnosed by computed tomography, with surgery the best and most highly recommended treatment. This particular presentation, to the best of our knowledge, has not yet been previously reported in the English language.

Colorectal cancer can metastasize to the liver by three potential routes; the most common are via the portal venous drainage of the liver and the lymphatic drainage of the large intestine with a third mechanism being direct invasion of the liver by a tumor of the hepatic flexure [1].

The use of fibrin sealant (FS) (Tisseel™) for mesh fixation in patients undergoing laparoscopic groin hernia surgery is a well-recognised technique in Europe, but no study to date has examined effect on quality of life (QoL) on patients undergoing FS mesh fixation. A prospective study was therefore conducted to examine the effects on QoL of patients undergoing laparoscopic groin hernia surgery using FS in the United Kingdom. Between March 2007 and January 2011, all patients undergoing laparoscopic total extra preperitoneal (TEP) groin hernia repair using FS were included in the study. A validated hernia questionnaire from The Royal College of Surgeons of England supplemented by the EORTC QLQ C-30 to assess the pre- and postoperative QoL, pain scores and health outcome measures was used. All the patient’s demographics, duration of surgery, size of hernia, recurrence, morbidity and hospital stay were recorded. Data from 92 patients (87 males and 5 females) with a median age of 46 years (range, 19–82 years) was collected for the study (response rate of 92/121, 73 %). A total of 58 patients (63 %) had a unilateral and 34 patients (37 %) a bilateral hernia repair, of which 6 (7 %) were recurrent inguinal hernia. The mean operating time for a unilateral hernia was 36 min (30–62), and that for a bilateral hernia was 59 min (51–83). There were no conversions to open surgery out of the 92 patients included with the recorded morbidity of 7 %. There were no early recurrences. Eighty-nine patients (98 %) of patients were discharged in the first 24 h after surgery. There was a significant statistical difference recorded in patients visual analogue pain score (VAS 0–10) before and after surgery (P

This report details the case of a patient presenting with a periampullary cancer and an abdominal aortic aneurysm who underwent endovascular repair of the aneurysm prior to pancreaticoduodenectomy. Use of the endovascular approach avoided the need for two major operative interventions.

A 60-year-old man presented with ureteric obstruction secondary to a mycotic right common iliac artery aneurysm complicating methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The diagnosis of MRSA was not known at the time of surgery, and in situ replacement of the aneurysm using a rifampicin-bonded prosthesis was performed. The patient made a full recovery, and to date there is no evidence of residual or recurrent infection. To our knowledge, this is the first reported case of mycotic iliac aneurysm infected with MRSA in the literature. We discuss the consequences and the considerable diagnostic and therapeutic problems that arise.

To the editor, We, the authors, read with interest the comments from Pellino and Selvaggi on our article [1]. We agree with the observation from Pellino et al. and colleagues that surgical expertise, method of mesh fixation as well as type of mesh used is likely to be the determining factor in post-operative chronic pain [2]. It is though mooted but remains to be demonstrated in any randomized controlled trial as to whether a patient’s relative weight and body mass index may determine mesh comfort, especially as ‘thin’ patients may more inclined to experience a foreign body sensation? Our study does demonstrate that fixation is a key factor with traumatic fixation being more inclined to result in increased post-operative discomfort. Further work is still required with trials aiming at long-term follow-up, however from previous studies and experience it would seem reasonable to predict that long-term follow-up may show little significant difference [3].

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.

Aims: Over the last decade cryotherapy has been reported to improve survival for patients with hepatic metastases. We compared our 5-year experience of cryoablative techniques for colorectal (CR) and non-colorectal (Non-CR) metastases. Methods: Data were analysed retrospectively from two centres in the North–West of England. Survival analyses were calculated using the Kaplan–Meier method. Results: Over a 7-year period (1993–2000), 57 patients underwent cryotherapy for malignant hepatic tumours. There were 36 males (63.2 per cent), and 21 females (36.8 per cent). The age of the patients ranged between 17 and 83 years (mean 60, median 57.8 years). Forty-one patients had CR metastases with between 1 and 11 lesions per patient, ranging in size from 2 to 10 cm. Preoperative carcinoembryonic antigen (CEA) levels (mean = 444.1 µg/L) were significantly reduced following treatment in the CR patients with a mean postoperative level of 6.22 µg/L (P = 0.002, McNemar test). Two patients developed cryoshock and four other patients suffered cardiorespiratory complications. The remaining 16 patients with Non-CR tumours (6 neuroendocrine metastases, 5 hepatocellular carcinomas (HCC), 3 sarcomas, 1 cholangiocarcinoma and 1 insulinoma) all received cryotherapy alone. There were no major complications in this group. The 3- and 5-year survivals for Non-CR and CR metastases were 80 and 32 per cent and 33 and 6 per cent, respectively. Survival for Non-CR metastases was significantly better than for CR metastases (P = 0.005, log rank test). Conclusion: Cryotherapy is an effective form of hepatic ablation. Cryotherapy for noncolorectal metastases has a greater long-term survival benefit with fewer complications when compared to colorectal metastases (P = 0.005, log rank test).