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To compare resection and survival outcomes of neoadjuvant chemoradiotherapy (CRT) and immediate surgery in patients with resectable pancreatic cancer (RPC) or borderline resectable pancreatic cancer (BRPC).In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards, a systematic review of randomized controlled trials (RCTs) was conducted. Random effects modeling was applied to calculate pooled outcome data. Likelihood of type 1 or 2 errors in the meta-analysis model was assessed by trial sequential analysis.A total of 400 patients from four RCTs were included. When RPC and BRPC were analyzed together, neoadjuvant CRT resulted in a higher R0 resection rate (risk ratio [RR]: 1.55,Neoadjuvant CRT might be beneficial for patients with BRPC, but not for patients with RPC. Nevertheless, the best available evidence does not include contemporary chemotherapy regimens. Patients with RPC and those with BRPC should not be combined in the same cohort in future studies.

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.

To evaluate comparative outcomes of robotic and laparoscopic left lateral hepatic sectionectomy (LLS).A systematic search of PubMed, Web of Science, EMBASE and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Overall, minor (Clavien-Dindo grade III) and major (Clavien-Dindo grade III) postoperative complications, mortality, volume of blood loss, conversion to an open procedure, procedure time, length of hospital stay, cost-effectiveness and R1 resection were the evaluated outcome measures.Seven comparative observational studies reporting a total of 319 patients of whom 150 underwent robotic LLS and the remaining 169 patients underwent laparoscopic LLS were included. The robotic approach was associated with significantly longer procedure time (MD: 29.40 min, p = 0.01) and higher cost (MD: $4170, p 0.00001) compared to the laparoscopic approach. There was no significant difference in overall postoperative morbidity (OR: 1.29, p = 0.62), Clavien-Dindo grade III (OR: 1.65, p = 0.49), Clavien-Dindo grade III (OR: 1.18, p = 0.85), perioperative mortality (RD: 0.00, p = 1.00), volume of blood loss (MD: 1.96 mls, p = 0.91), conversion to an open procedure (RD: - 0.02, p = 0.46), length of hospital stay (MD: 0.22 day, p = 0.52) or R1 resection (RD:0.00, p = 1.00) between two groups.Meta-analysis of the best available evidence (level 2) demonstrated that robotic LLS is associated with significantly longer procedure time and higher cost and similar perioperative outcomes compared to the laparoscopic approach. Future randomised studies are required to evaluate short-term perioperative, long-term oncological and surgeon-centred outcomes.

Background Sharp penetrating trauma represents 4.1% - 6.9% of all major trauma cases in the UK. The incidence of Sharp penetrating trauma is rising, with 47,000 offences in England and Wales in 2019. There has been limited published data on the victims of sharp penetrating trauma. Methods We performed a single centre retrospective case note review of patients admitted to an urban major trauma centre following an assault with a sharp object from 1st January 2014 to the 31st December 2018. Data was collected on demographics, injury pattern, management, and outcome. Results In total, 686 patients were included in the study. There was a year on year increase of admissions with sharp penetrating trauma from 100 admissions in 2014, to 194 in 2018. The majority of patients were male, with a mean age of 31, and 73% of our patients were of Caucasian ethnicity. Patients presented most frequently on weekends (53%). The length of stay increased over the study period from 2.3 days in 2014 to 4.0 days in 2018. The thorax was the most commonly injured body region, involved in 29% of presentations, followed by the abdomino-pelvis (21%). 51% of patients presented with multiple injuries, and the average number of stab wounds per patient increased from 1.95 in 2014 to 2.40 in 2018. Conclusions Our study has demonstrated the incidence and severity of sharp penetrating trauma is increasing in central Manchester. The authors advocate the creation of a national knife crime database to further the implementation of prevention strategies.

Backgrounds Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy. Methods A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included one-, three- and five-year survival, overall survival, disease-free survival and complication rate. Results Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at one-, three- and five-years was 83.3–100%, 58.3–80% and 50–80%, respectively, with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease-free survival was 35–56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence. Conclusion Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.

Aims To compare resection and survival outcomes of CRT and immediate surgery in patients with resectable and borderline resectable pancreatic cancer Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all randomised controlled trials (RCTs) investigating outcomes of neoadjuvant CRT versus immediate surgery in patients with resectable and borderline resectable pancreatic cancer. Two treatment strategies were compared using direct comparison meta-analysis model. Random effects modelling was applied to calculate pooled outcome data. The risks of Type1 or Type2 error in the meta-analysis model were assessed using trial sequential analysis (TSA) model. The certainty of evidence was assessed using GRADE system. Results 400 patients from 4 RCTs were included. When resectable and borderline resectable diseases were analysed together, neoadjuvant CRT resulted in higher R0 resection rate (RR: 1.55, P=0.004), longer overall survival (MD: 3.75, P=0.009) but lower overall resection rate (RR: 0.83, P=0.008). When resectable and borderline resectable diseases were analysed separately, neoadjuvant CRT improved R0 resection rate (RR: 3.72, P=0.004) and overall survival (MD: 6.64, P=0.004) in patients with borderline resectable pancreatic cancer but it did not improve R0 resection rate (RR: 1.18, P=0.13) and overall survival (MD: 0.94, P=0.57) in patients with resectable pancreatic cancer. Conclusions Evidence from RCTs suggests that neoadjuvant CRT improves R0 resection rate and overall survival in patients with borderline resectable pancreatic cancer but not in patients with resectable pancreatic cancer. Nevertheless, the best available evidence does not include the contemporary chemotherapy regimens; therefore, more definite conclusions would depend on the results of future RCTs.

Aims to evaluate the procedural outcomes of laparoscopic caudate lobe resection. Methods We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting the outcomes of laparoscopic resection of caudate lobe of liver. The population of interest included adult patients with benign or malignant lesions located in caudate lobe of liver. The intervention of interest included laparoscopic resection of caudate lobe of liver. Random-effects models were applied to calculate pooled outcome data. Results 196 patients from 12 studies were included. The mean operative time, volume of intraoperative blood loss, and length of hospital stay were 225 mins (181–269), 134 ml (85–184), and 7 days (5–9), respectively. The pooled risks of need for intraoperative transfusion was 2% (0–5%), conversion to open surgery was 3% (1–6%), need for intra-abdominal drain was 6% (0–19%), postoperative mortality was 1% (0–3%), biliary leakage was 2% (0–4%), intra-abdominal abscess was 2% (0–4%), biliary stenosis was 1% (0–4%), postoperative bleeding was 1% (0–3%), pancreatic fistula was 1% (0–4%), pulmonary complications was 2% (1–5%), paralytic ileus was 1% (0–4%), and need for reoperation was 1% (0–4%). Conclusions Evidence from case series suggests that laparoscopic approach may be safe, feasible and promising for resection of lesions located in caudate lobe of liver. The findings of current study can be used for hypothesis synthesis in future studies and can be used to inform surgeons and patients about the estimated risks of perioperative complications until a higher level of evidence is available.

Open and laparoscopic modalities are employed for treatment of sportsman’s hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman’s hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman’s hernia repair. A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle–Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed. 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques. There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.

This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy. In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan–Meier survival statistics. A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3–25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0–26.4%) in-hospital mortality, and 40.2% (95% CI 35.9–44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82–3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30–3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50–2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07–2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36–3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011). Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:− 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: − 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: − 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: − 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12 h (MD: − 0.66, P

A systematic review was conducted in compliance with PRISMA statement standards to identify all studies reporting outcomes of laparoscopic resection of benign or malignant lesions located in caudate lobe of liver. Pooled outcome data were calculated using random-effects models. A total of 196 patients from 12 studies were included. Mean operative time, volume of intraoperative blood loss, and length of hospital stay were 225 minutes (95% confidence interval [CI], 181-269 minutes), 134 mL (95% CI, 85-184 mL), and 7 days (95% CI, 5-9 days), respectively. The pooled risk of need for intraoperative transfusion was 2% (95% CI, 0%-5%). It was 3% (95% CI, 1%-6%) for conversion to open surgery, 6% (95% CI, 0%-19%) for need for intra-abdominal drain, 1% (95% CI, 0%-3%) for postoperative mortality, 2% (95% CI, 0%-4%) for biliary leakage, 2% (95% CI, 0%-4%) for intra-abdominal abscess, 1% (95% CI, 0%-4%) for biliary stenosis, 1% (95% CI, 0%-3%) for postoperative bleeding, 1% (95% CI, 0%-4%) for pancreatic fistula, 2% (95% CI, 1%-5%) for pulmonary complications, 1% (95% CI, 0%-4%) for paralytic ileus, and 1% (95% CI, 0%-4%) for need for reoperation. Although the available evidence is limited, the findings of the current study might be utilized for hypothesis synthesis in future studies. They can be used to inform surgeons and patients about estimated risks of perioperative complications until a higher level of evidence is available.

Background: This study reports the outcome of a work-up programme for resection of peri-hilar cholangiocarcinoma (PH-CCA) without the use of staging laparoscopy. Methods: This is a clinical case cohort series of patients undergoing surgical resection of PH-CCA without the use of staging laparoscopy in the work-up algorithm. During the 13 years from 1 January 2009 to 1 January 2022, 32 patients underwent laparotomy for planned surgical resection of PH-CCA. Data were collected on demographic profile, admission biochemistry, radiology, pre-operative intervention, operation and outcome, together with post-operative complications and disease-free and overall survival. Results: All patients underwent pre-operative contrast-enhanced CT. Twenty-four (75%) underwent pre-operative MR. Twenty-three (72%) underwent pre-operative biliary drainage. Twenty-nine patients (91%) had either type III or IV peri-hilar cholangiocarcinoma. One patient (3%) in this series underwent a non-resectional laparotomy. Twenty-nine (91%) had a final histopathological diagnosis of PH-CCA. One further patient had a final diagnosis of an intraductal papillary neoplasm of the biliary tree (IPNB) with high-grade dysplasia but no invasive cancer. Eleven patients (36%) received chemotherapy after surgery. The median (95% CI) time to recurrence was 14 (7–31) months. The median survival was 25 (18-upper limit not reached) months. Conclusion: This cohort of 32 patients undergoing attempted resection for PH-CCA without the use of staging laparoscopy in the work-up algorithm indicates that with careful attention to patient fitness and cross-sectional and interventional radiologic/endoscopic imaging, a very low non-therapeutic laparotomy rate of 3% can be achieved and sustained.

To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery. We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 min (95% CI 102–172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5–97.5, I2 = 0%), papillary access success was 95.3% (95% CI 92.5–97.5, I2 = 0%), cannulation success was 95.3% (95% CI 92.5–97.5, I2 = 0%), sphincterotomy success was 96.1% (95% CI 93.5–98.1, I2 = 0%), and stone removal success was 95.9% (95% CI 92.4–98.4, I2 = 0%). Conversion to open was required in 4.7% (95% CI 2.5–7.6, I2 = 0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3–8, I2 = 17%), cholangitis in 1.7% (95% CI 0.5–3.6, I2 = 0%), and perforation in 3.7% (95% CI 1.8–6.3, I2 = 0%). The length of hospital stay was 3 days (95% CI 2–4). Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.

Aims. To compare short-term and long-term outcomes of preoperative endoscopic biliary drainage (EBD) and percutaneous biliary drainage (PBD) in patients with Klatskin tumor undergoing curative surgery. Methods. We conducted a search of electronic information sources to identify all studies comparing EBD and PBD in patients with Klatskin tumor undergoing curative surgery. We used the Newcastle-Ottawa Scale to assess the risk of bias observational studies. Random-effects or fixed-effects modeling was applied as appropriate to calculate pooled outcome data. Results. We identified 9 observational studies, enrolling a total of 1436 patients. The patients in the PBD group had more advanced disease than those in EBD group in terms of Bismuth-Corlette classification and tumor classification. EBD was associated with higher risks of postprocedural complications (odds ratio [OR] =2.24, P = .001), conversion to another drainage method (OR =11.16, P < .00001), cholangitis (OR = 4.58, P < .0001), and pancreatitis (OR = 8.90, P = .009) than PBD; there was no difference between the 2 methods in terms of technical success (OR = 0.79, P = .50) and tube dislocation (OR = 0.81, P = .54). Regarding the postoperative outcomes, there was no difference in terms of 30-day mortality (OR = 0.61, P = .16) and major postoperative complications (OR = 0.60, P = .06). Regarding the long-term outcomes, EBD was associated with lower risks of seeding metastasis (OR = 0.46, P = .0004) and 5-year recurrence (OR = 0.72, P = .010), and better 5-year survival (OR = 1.62, P = .001). Conclusions. EBD may be associated with higher procedure-related complications compared with PBD as a preoperative biliary drainage method in patients with Klatskin tumor undergoing curative surgery. The available evidence on long-term oncological and survival outcomes are subject to confounding by indication, and high-quality randomized controlled trials are required for definite conclusions.

To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery. The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle–Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated. Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: −1.40, P

To compare performance of the Hajibandeh Index (HI) and National Emergency Laparotomy Audit (NELA) score in predicting postoperative mortality in patients undergoing emergency laparotomy.In compliance with STROCSS guidelines for observational studies a cohort study was conducted. All patients aged over 18 who underwent emergency laparotomy between January 2014 and January 2021 in our centre were considered eligible for inclusion. The HI and NELA indices in predicting 30-day and 90-day postoperative mortality were compared. The discrimination of each test was evaluated using Receiver Operating Characteristic (ROC) curve analysis, classification using the classification table and calibration using a plotted diagram of the expected versus observed mortality rates.Analysis of 700 patients showed that the predictive performance of the HI and NELA models were comparable (30-day mortality: AUC: 0.86 vs 0.87, P = 0.557; 90-day mortality: AUC: 0.81 vs 0.84, P = 0.0607). In terms of 30-day mortality, HI was significantly better than the NELA model in predicting postoperative mortality in patients aged over 80 (AUC: 0.85 vs 0.72, P = 0.0174); however, the performances of both tools were comparable in patients with ASA status above 3 (AUC: 0.82 vs 0.82, P = 0.9775), patients with intraperitoneal contamination (AUC: 0.77 vs 0.85, P = 0.0728) and patients who needed a bowel resection (AUC: 0.85 vs 0.88, P = 0.2749). In terms of 90-day mortality, HI was significantly better than the NELA model in predicting mortality in patients aged over 80 (AUC: 0.82 vs 0.71, P = 0.0214); however, NELA had better predictive value in patients with intraperitoneal contamination (AUC: 0.76 vs 0.85, P = 0.0268); the performances of both tools were comparable in patients with ASA status above 3 (AUC: 0.77 vs 0.80, P = 0.2582), and patients who needed a bowel resection (AUC: 0.81 vs 0.86, P = 0.05). Both tools were comparable in terms of classification and calibration.Hajibandeh index was better than the NELA score in predicting postoperative 30-day and 90-day mortality in patients aged over 80 undergoing emergency laparotomy. Its performance in predicting 30-day and 90-day mortality was comparable with NELA score in other subgroups except 90-day mortality in patients with intraperitoneal contamination where the performance of NELA was better. We encourage other researchers to validate HI in predicting mortality following emergency laparotomy.

ObjectivesAn algorithm was designed aiming to provide consistency of pancreatic enzyme replacement therapy (PERT) dosing/titration across healthcare professionals in pancreaticobiliary cancers (PBC). This prospective observational study aimed to validate this algorithm.MethodsConsecutive patients with inoperable or post-operative PBC with pancreatic exocrine insufficiency (PEI) symptoms, not taking PERT, or taking below the algorithm ‘starting dose’, were eligible. A dietitian or clinical nurse specialist reviewed patients for up to 3 weeks, titrating PERT as per the algorithm. Feasibility of algorithm deliverability was assessed by the percentage of patients with successful completion (primary objective). ResultsEligible patients (n = 25): at baseline 22 taking PERT [100% on suboptimal doses, 54.5% taking incorrectly], 3 initiated PERT due to PEI symptoms. Algorithm completion 20/25 (80%) patients, confirming deliverability by dietitians (11/12; 92%) and Clinical nurse specialist (9/13; 69%). Symptom resolution in 8/19 (42%), 3/7 (43%) and 1/3 (33%) patients at 1st, 2nd and 3rd reviews, respectively; advice compliance between 63-86%. ConclusionThis algorithm provides a structured method to titrate PERT. At diagnosis, all patients with PBC should be assessed for PEI and adequate PERT initiated. Regular reviews are required for timely symptom resolution and adequate escalation, facilitating differential diagnosis if refractory symptoms exist.Key wordsPancreatic Exocrine Insufficiency; Pancreatic Cancer; Pancreatic Enzyme Replacement Therapy

Background Pancreatic cancer is currently the fourth most common cause of cancer-related mortality in the economically developed world and is set to become the second most common cause of cancer-related mortality within the next few years. NICE guidance makes a strong recommendation to offer up-front surgery to people with resectable pancreatic cancer, without preoperative biliary drainage, if sufficiently fit for surgery. The aim of this study was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting, to examine perioperative outcomes and to perform an intention to treat analysis to evaluate long-term survival between the two groups. Methods 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. Data related to patient and tumour characteristics, biliary drainage, surgery and histopathology were gathered and analysed from a prospectively maintained electronic database. Post-operative complications were defined and graded according to the definitions of the International Study Group on Pancreatic Surgery (ISGPS) and the Clavien-Dindo system. Data related to adjuvant treatment, disease recurrence and overall survival were also analysed. Results In this retrospective study of 216 consecutive operable patients, 70 followed the fast-track (FT) pathway and 146 had pre-operative biliary drainage (PBD). All 70 patients in the fast-track 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 much shorter in the FT group (median range) 8 vs 43 days p Conclusions These data strengthen the existing evidence that, for a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage. The optimal comparison to the neoadjuvant approach is upfront fast-track surgery without biliary drainage followed by adjuvant therapy.

Aims To evaluate the risk and predictors of postoperative mortality in octogenarians undergoing emergency laparotomy. Methods In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan–Meier survival statistics. Results A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR: 2.49,95% CI 1.82-3.38,P Conclusions Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carries a high risk of immediate postoperative and 1-year mortality. There is a need to incorporate modern prognosticators into the available preoperative mortality risk assessment tools.

Aims To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery. Methods We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data. Results A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 minutes (95% CI 102-172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5-97.5,I2=0%), papillary access success was 95.3% (95% CI 92.5-97.5,I2=0%), cannulation success was 95.3% (95% CI 92.5-97.5,I2=0%), sphincterotomy success was 96.1% (95% CI 93.5-98.1,I2=0%), and stone removal success was 95.9% (95% CI 92.4-98.4, I2=0%). Conversion to open was required in 4.7% (95% CI 2.5-7.6,I2=0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3-8,I2=17%), cholangitis in 1.7% (95% CI 0.5 to 3.6,I2=0%), and perforation in 3.7% (95% CI 1.8- 6.3,I2=0%). The length of hospital stay was 3 days (95% CI 2-4). Conclusions Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.

Objectives To evaluate comparative outcomes of spinal anaesthesia (SA) and general anaesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia. Methods We systematically searched MEDLINE; EMBASE; CINAHL; CENTRAL, and bibliographic reference lists. Post-operative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. Results We identified 5 studies enrolling 1,518 patients (2,134 hernia) evaluating outcomes of laparoscopic TEP repair under SA (n = 1,277 patients, 1,877 hernia) or GA (n = 241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours (MD: - 0.32, P Conclusions Although TEP inguinal hernia repair under SA may reduce pain in early postoperative period, it seems to be associated with increased postoperative morbidity and longer procedure time. It may be an appropriate anaesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.

Aims to compare the outcomes of three-port and four-port laparoscopic cholecystectomy. Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port versus four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of the available evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2524 patients from 17 studies showed that three-port and four-port laparoscopic cholecystectomy techniques were comparable in terms of operative time (MD:-0.13,P=0.88), conversion to open operation (OR:0.80,P=0.43), gallbladder perforation (OR:1.43,P=0.13), bleeding from gallbladder bed (OR: 0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD:-0.00,P=0.81), bile or stone spillage (OR:1.67,P=0.08), port site infection (OR:0.90,P=0.76) and need for reoperation (RD:-0.00,P=0.94). However, the three-port technique was associated with lower VAS pain score at 12 hours (MD:-0.66,P Conclusions Robust evidence (Level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Aim Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications. Method A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models. Results Fourteen studies were identified including four randomized controlled trials (RCTs) and 10 observational studies reporting a total of 2 031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction. Conclusions Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomized studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Introduction Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy reported in literature – 5-year survival rate Method A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included 1-, 3- and 5-year survival, overall survival, disease-free survival, and complication rates. Results Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at 1-, 3- and 5-years was 83.3-100%, 58.3-80% and 50-80% respectively with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease free survival was 35-56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence. Conclusions Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Eight registered clinical trials will report on 300 more patients undergoing LT for NRCLM over the next 10 years: concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.

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.

Open pancreaticoduodenectomy has a high complication and measurable mortality rate. Recent reports (based across multiple surgical disciplines) demonstrate that elevated postoperative high sensitivity troponin T (hsTnT) predicts adverse outcomes in non-cardiac surgery. The aim of this study was to evaluate postoperative hsTnT as a prognostic marker of mortality, major adverse cardiovascular events (MACE), post-operative non-cardiac complications and length of stay (including intensive care stay) in open pancreaticoduodenectomy. A retrospective review of open pancreaticoduodenectomy patients was undertaken from 01/10/2017–31/03/2019. Receiver operating characteristic (ROC) curves were calculated to identify ideal cut-off values for hsTnT. Univariate and multivariate analyses were performed to scrutinize the relationship between mean hsTnT and 30-day, 90-day mortality, MACE, post-operative non-cardiac complications and length of stay. One hundred and nine patients were identified. ROC curves demonstrated a strong correlation between elevated mean hsTnT and 30-day, 90-day mortality and MACE (AUC = 0.937, AUC = 0.852, AUC = 0.779, respectively). Multivariate analysis showed mean hsTnT > 21 ng/l was significantly associated with 90-day mortality (OR 43.928, p = 0.004) and MACE (OR 8.177, p = 0.048). HsTnT is predictive of mortality and MACE in the context of open pancreaticoduodenectomy. Association between hsTnT and prolonged critical care stay was less significant. Non-cardiac complications and length of stay show no significant association with hsTnT.

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:- 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: - 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: - 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: - 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12 h (MD: - 0.66, P 0.00001) and 24 h (MD: - 0.54, P 0.00001) postoperatively, shorter length of hospital stay (MD:-0.09, P = 0.41), and shorter time to return to normal activities (MD: - 0.79, P = 0.02). Trial sequential analysis confirmed that the meta-analysis was conclusive with no significant risks of type 1 or type 2 error. Robust evidence (level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Background Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications. Methods A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models. Results Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction. Discussion Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Background: Pancreaticoduodenectomy is associated with high rates of morbidity. This combined with the psychological burden of cancer, may impact on a patient’s quality of life (QoL), which can be measured by using patient-reported outcomes (PRO). Objective: To perform a systematic review to evaluate the measurement of PRO after pancreaticoduodenectomy for cancer. Methods: 7 different databases were searched using 2 groups of search terms, one relating to pancreaticoduodenectomy, and one to PRO. Three authors screened the search results independently in a systematic manner based on predefined inclusion and exclusion criteria. Results: 27 studies, with 2173 eligible patients were included in the final analysis. Most of the included studies used validated instruments. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire was most popular and used in 12 studies. The methodology of all included studies was also scrutinised. 12 studies were deemed to have high quality methodology according to pre-defined criteria. Conclusion: The instruments and methods used to measure PRO are variable. The quality of PRO within the available literature has improved over time, as has the number of studies measuring PRO. PRO should be measured with uniformity in future trials so that patients can be provided with more comprehensive information regarding post-operative recovery and QoL during the shared decision-making process preoperatively.

Latest cancer statistics in the USA estimate that around 10,590 new cases and 1,590 deaths of small intestinal cancers will be recorded in 2019,1 which has increased compared with previous statistics (8,070 and 1,150 new cases and deaths were estimated in 20122). Small bowel adenocarcinomas are likely to represent only 40% of all small bowel malignancies3 and 2% of all gastrointestinal tumours.4 Unfortunately, prognosis is poor, with around 38% of patients being diagnosed at stages when synchronous metastases are identified; 5-year survival rate is less than 30% and median overall survival is estimated to be around 19 months.4 Due to their low incidence, prospective data to inform the most adequate management of small bowel adenocarcinoma is lacking and most treatment recommendations are being based on expert agreement and relying on extrapolated data from colon cancer.4 This is despite the fact that genomic profiling suggests that small bowel adenocarcinomas are a ‘molecularly unique intestinal entity’ when compared with counterparts such as colorectal and gastric cancer.5 In addition, within small bowel adenocarcinomas, duodenal primaries seem to demonstrate genomic aberrations more typical of upper gastrointestinal malignancies such as pancreatic (CDKN2A/B)6 or gastric cancer (ERBB2/HER2).7 These findings may explain the worse prognosis and challenging management of duodenal adenocarcinoma compared with other small bowel adenocarcinomas. In the setting of small bowel adenocarcinoma, duodenal tumours account for around 50% of these. Almost 40% of small bowel adenocarcinoma present with lymph node invasion.4 Thus, a significant number of patients may present with locally advanced disease, in which scenario, a neoadjuvant approach with systemic chemotherapy could be of interest. Unfortunately, no data for small bowel or duodenal adenocarcinoma exist in this setting and management is extrapolated from other disease groups. In addition, after surgery, the role of adjuvant …

To compare baseline demographics, operative, and survival outcomes of randomised controlled trials (RCTs) comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer METHODS: In compliance with PRISMA standards we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors.Overall, 724 patients from 5 RCTs were included. The included populations were comparable in terms of baseline characteristics. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR 0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. The results remained consistent through subgroup analyses based on lymph node positive or negative status and studies from the West and East.Robust evidence from randomised controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.

OBJECTIVES To evaluate comparative outcomes of spinal anesthesia (SA) and general anesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia. METHODS We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Postoperative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. RESULTS We identified 5 comparative studies reporting a total of 1518 patients (2134 hernia) evaluating outcomes of laparoscopic TEP inguinal hernia repair under SA (n=1277 patients, 1877 hernia) or GA (n=241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours [mean difference (MD): -0.32; 95% confidence interval (CI), -0.45 to -0.20; P

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.

This study undertook the in vivo measurement of surface pressures applied by the fingers of the surgeon during typical representative retraction movements of key human abdominal organs during both open and hand-assisted laparoscopic surgery. Surface pressures were measured using a flexible thin-film pressure sensor for 35 typical liver retractions to access the gall bladder, 36 bowel retractions, 9 kidney retractions, 8 stomach retractions, and 5 spleen retractions across 12 patients undergoing open and laparoscopic abdominal surgery. The maximum and root mean square surface pressures were calculated for each organ retraction. The maximum surface pressures applied to these key abdominal organs are in the range 1 to 41 kPa, and the average maximum surface pressure for all organs and procedures was 14 ± 3 kPa. Surface pressure relaxation during the retraction hold period was observed. Generally, the surface pressures are higher, and the rate of surface pressure relaxation is lower, in the more confined hand-assisted laparoscopic procedures than in open surgery. Combined video footage and pressure sensor data for retraction of the liver in open surgery enabled correlation of organ retraction distance with surface pressure application. The data provide a platform to design strategies for the prevention of retraction injuries. They also form a basis for the design of next-generation organ retraction and space creation surgical devices with embedded sensors that can further quantify intraoperative retraction forces to reduce injury or trauma to organs and surrounding tissues.

Objectives to investigate the impact of weekend effect on postoperative mortality in patients undergoing emergency General Surgery operations across the world. Methods A search of electronic information sources was conducted to identify all studies investigating the weekend effect in patients undergoing emergency General Surgery operations. Emergency operation during weekend was considered as exposure of interest, emergency operation during weekdays as comparison of interest, and postoperative mortality as the outcome of interest. Random or fixed effects modelling were applied to calculate pooled outcome data. Results Overall, 10 studies, enrolling 394,646 patients, were included. Worldwide, emergency General surgery operation during weekend was associated with a higher risk of postoperative mortality compared to weekdays (OR: 1.08, 95% CI 1.02, 1.14, P = 0.008, moderate quality evidence). The weekend effect was variable across the world. Although emergency operation during weekend was associated with a higher risk of postoperative mortality in the USA (OR: 1.12, 95% CI 1.01, 1.24, P = 0.03, moderate quality evidence) and Europe (OR: 1.37, 95% CI 1.11, 1.69, P = 0.003, moderate quality evidence), there was no difference in postoperative mortality between weekend and weekday groups in the UK (OR: 1.04, 95% CI 0.97, 1.11, P = 0.30, moderate quality evidence) and South Africa (OR: 0.79, 95% CI 0.44, 1.42, P = 0.43, moderate quality evidence). Conclusions The weekend effect in emergency General Surgery is variable across the world. Although it seems to be significant in the USA and Europe, it does not increase the risk of postoperative mortality in the UK. Future studies should focus on differences in staffing levels and available resources at weekends in emergency General surgery settings across the world.

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.

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.