Randomised, placebo-controlled, phase 3 trial of the effect of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) on colorectal cancer recurrence and survival after surgery for resectable liver metastases: EPA for Metastasis Trial 2 (EMT2) study protocol

INTRODUCTION

There remains an unmet need for safe and cost-effective adjunctive treatment of advanced colorectal cancer (CRC). The omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) is safe, well-tolerated and has anti-inflammatory as well as antineoplastic properties. A phase 2 randomised trial of preoperative EPA free fatty acid 2 g daily in patients undergoing surgery for CRC liver metastasis showed no difference in the primary endpoint (histological tumour proliferation index) compared with placebo. However, the trial demonstrated possible benefit for the prespecified exploratory endpoint of postoperative disease-free survival. Therefore, we tested the hypothesis that EPA treatment, started before liver resection surgery (and continued postoperatively), improves CRC outcomes in patients with CRC liver metastasis.

METHODS AND ANALYSIS

The EPA for Metastasis Trial 2 trial is a randomised, double-blind, placebo-controlled, phase 3 trial of 4 g EPA ethyl ester (icosapent ethyl (IPE; Vascepa)) daily in patients undergoing liver resection surgery for CRC liver metastasis with curative intent. Trial treatment continues for a minimum of 2 years and maximum of 4 years, with 6 monthly assessments, including quality of life outcomes, as well as annual clinical record review after the trial intervention. The primary endpoint is CRC progression-free survival. Key secondary endpoints are overall survival, as well as the safety and tolerability of IPE. A minimum 388 participants are estimated to provide 247 CRC progression events during minimum 2-year follow-up, allowing detection of an HR of 0.7 in favour of IPE, with a power of 80% at the 5% (two sided) level of significance, assuming drop-out of 15%.

ETHICS AND DISSEMINATION

Ethical and health research authority approval was obtained in January 2018. All data will be collected by 2025. Full trial results will be published in 2026. Secondary analyses of health economic data, biomarker studies and other translational work will be published subsequently.

TRIAL REGISTRATION NUMBER

NCT03428477.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

OGC P19 The future insights of evaluating the circumferential resection margin (CRM) status in oesophageal cancer: A 12-year cohort study

Background

The definition of CRM (circumferential resection margins) for oesophageal cancers varies among the international pathological bodies with an ongoing controversy about the optimal definition. There is also no enough data about the prognostic relevance of different sites in CRM. In this study, we examined the prognostic impacts of different CRM distances and sites.

Methods

This study included patients who had curative oesophagectomy for oesophageal cancer between 2010 till June 2021. Follow up till April 2022 was achieved. CRM status was carefully examined for the distance and site of involved tumour cells. Patients with involved proximal or distal margins were excluded. The outcomes between different CRM margins were retrospectively analysed. The long-term follow up data was obtained via direct contact with the patients during our oncological clinics, cross-checked with our hospital/national patients’ electronic databases.

Results

456 patients were included in this study. Involved tumour cells within 1mm of CRM was observed in 192 patients (42.1%). CRM+ (<1mm) was associated with worse overall (OS) and disease-free survival (DFS) (22.8 and 16.3 months respectively) compared to CRM-negative (47.7 and 45.1 months respectively), (p-value <0.001 for both). CRM+ (0mm) had worse OS and DFS (20.5 and 12 months respectively) compared to CRM+(0.1–1mm) (26.4 and 20 months respectively), (p-values 0.028 and 0.006 respectively). CRM-positive posterior margin was the most common involved site (32%), but was associated with better OS and DFS compared to anterior and lateral sites, (p-values 0.1 and 0.08 respectively).

Conclusions

The site and distance of tumour cells within CRM should be rigorously assessed in oesophagectomy specimens. The presence of tumour cells within 1mm of CRM was an independent factor for OS and DFS. The CRM+(0 mm) had significant lower survival rates compared to other CRM+ distances (0.1–1 mm). The involved margin sites within CRM had different survival rates, with superiority towards posterior resection margins.

Omega-3 polyunsaturated fatty acids: moving towards precision use for prevention and treatment of colorectal cancer

Data from experimental studies have demonstrated that marine omega-3 polyunsaturated fatty acids (O3FAs) have anti-inflammatory and anticancer properties. In the last decade, large-scale randomised controlled trials of pharmacological delivery of O3FAs and prospective cohort studies of dietary O3FA intake have continued to investigate the relationship between O3FA intake and colorectal cancer (CRC) risk and mortality. Clinical data suggest that O3FAs have differential anti-CRC activity depending on several host factors (including pretreatment blood O3FA level, ethnicity and systemic inflammatory response) and tumour characteristics (including location in the colorectum, histological phenotype (eg, conventional adenoma or serrated polyp) and molecular features (eg, microsatellite instability, cyclooxygenase expression)). Recent data also highlight the need for further investigation of the effect of O3FAs on the gut microbiota as a possible anti-CRC mechanism, when used either alone or in combination with other anti-CRC therapies. Overall, these data point towards a precision approach to using O3FAs for optimal prevention and treatment of CRC based on mechanistic understanding of host, tumour and gut microbiota factors that predict anticancer activity of O3FAs.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Changes in plasma chemokine C-C motif ligand 2 levels during treatment with eicosapentaenoic acid predict outcome in patients undergoing surgery for colorectal cancer liver metastasis

The mechanism of the anti-colorectal cancer (CRC) activity of the omega-3 fatty acid eicosapentaenoic acid (EPA) is not understood. We tested the hypothesis that EPA reduces expression of chemokine C-C motif ligand 2 (CCL2), a pro-inflammatory chemokine with known roles in metastasis.We measured CCL2 in clinical samples from a randomized trial of EPA in patients undergoing liver surgery for CRC liver metastasis (LM) and preclinical models. Genome-wide transcriptional profiling of tumors from EPA-treated patients was performed.EPA decreased CCL2 synthesis by CRC cells in a dose-dependent manner. CCL2 was localized to malignant epithelial cells in human CRCLM. EPA did not reduce CCL2 content in human or mouse tumors compare to control. However, EPA treatment was associated with decreased plasma CCL2 levels compared with controls (P=0.04). Reduction in plasma CCL2 following EPA treatment predicted improved disease-free survival (HR 0.32; P=0.003). Lack of 'CCL2 response' was associated with a specific CRCLM gene expression signature.In conclusion, reduction in plasma CCL2 in patients with CRCLM treated with EPA predicts better clinical outcome and a specific tumor gene expression profile. Further work is needed to validate CCL2 as a therapeutic response biomarker for omega-3 fatty acid treatment of CRC patients.

Surveillance Is Important After Surgical Excision of Giant Fibrovascular Polyps of the Esophagus

Giant fibrovascular polyps of the esophagus are rare benign tumors arising from the cervical esophagus or hypopharynx. Radiologic and endoscopic investigation may struggle to identify a stalk or to delineate the tumor as luminal or submucosal in origin. Excision is advised, although the diagnosis, and therefore the optimal operative approach, may not be apparent until the time of operation. Individual case reports describe the technical success of surgical excision but rarely include follow-up. Our case series highlights the range of approaches for surgical excision and also the importance of long-term follow-up because of the risk of recurrence and potential for airway obstruction.

A liquid chromatography-tandem mass spectrometry method to measure fatty acids in biological samples

As pre-clinical and clinical research interest in ω-3 polyunsaturated fatty acids (PUFA) increases, so does the need for a fast, accurate and reproducible analytical method to measure fatty acids (FA) in biological samples in order to validate potential prognostic and predictive biomarkers, as well as establishing compliance in ω-3 PUFA intervention trials. We developed a LC-ESI-MS/MS method suitable for high throughput development to measure FAs and validated it in the context of treatment with the ω-3 PUFA eicosapentaenoic acid (EPA). Uniquely we directly compared the LC-ESI-MS/MS method to a GC-MS protocol. We demonstrated the LC-ESI-MS/MS method is accurate and reproducible, with coefficients of variation consistently below 15% for each PUFA analysed. The relative FA content values correlated well with those obtained by GC-MS (r²=0.94, p<0.001 for EPA) in vitro. The data obtained following analysis of FA content of liver tissues from mice fed an eicosapentaenoic acid enriched diet showed similar results to that of published studies in which GC-MS was used. The LC-ESI-MS/MS method allows concomitant analysis of unesterified (free, unbound) and esterified (bound) FAs in biological samples, allowing investigation of different PUFA pools in cells and tissues.

Measurement of red blood cell eicosapentaenoic acid (EPA) levels in a randomised trial of EPA in patients with colorectal cancer liver metastases

We investigated red blood cell (RBC) PUFA profiles, and the predictive value of RBC EPA content for tumour EPA exposure and clinical outcomes, in the EMT study, a randomised trial of EPA in patients awaiting colorectal cancer (CRC) liver metastasis surgery (Cockbain et al., 2014) [8]. There was a significant increase in RBC EPA in the EPA group (n=43; median intervention 30 days; mean absolute 1.26[±0.14]% increase; P<0.001), but not in the placebo arm (n=45). EPA incorporation varied widely in EPA users and was not explained by treatment duration or compliance. There was little evidence of 'contamination' in the placebo group. The EPA level predicted tumour EPA content (r=0.36; P=0.03). Participants with post-treatment EPA≥1.22% (n=49) had improved OS compared with EPA <1.22% (n=29; HR 0.42[95%CI 0.16-0.95]). RBC EPA content should be evaluated as a biomarker of tumour exposure and clinical outcomes in future EPA trials in CRC patients.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Management of gallbladder dyskinesia: patient outcomes following positive ⁹⁹mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy

AIMS

To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC).

METHODS AND MATERIALS

Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution.

RESULTS

One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC.

CONCLUSION

In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.

Anticolorectal cancer activity of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid

BACKGROUND

Oral administration of the omega-3 fatty acid eicosapentaenoic acid (EPA), as the free fatty acid (FFA), leads to EPA incorporation into, and reduced growth of, experimental colorectal cancer liver metastases (CRCLM).

DESIGN

We performed a Phase II double-blind, randomised, placebo-controlled trial of EPA-FFA 2 g daily in patients undergoing liver resection surgery for CRCLM. The patients took EPA-FFA (n=43) or placebo (n=45) prior to surgery. The primary end-point was the CRCLM Ki67 proliferation index (PI). Secondary end-points included safety and tolerability of EPA-FFA, tumour fatty acid content and CD31-positive vascularity. We also analysed overall survival (OS) and disease-free survival (DFS).

RESULTS

The median (range) duration of EPA-FFA treatment was 30 (12-65) days. Treatment groups were well matched with no significant difference in disease burden at surgery or preoperative chemotherapy. EPA-FFA treatment was well tolerated with no excess of postoperative complications. Tumour tissue from EPA-FFA-treated patients demonstrated a 40% increase in EPA content (p=0.0008), no difference in Ki67 PI, but reduced vascularity in 'EPA-naïve' individuals (p=0.075). EPA-FFA also demonstrated antiangiogenic activity in vitro. In the first 18 months after CRCLM resection, EPA-FFA-treated individuals obtained OS benefit compared with placebo, although early CRC recurrence rates were similar.

CONCLUSIONS

EPA-FFA therapy is safe and well tolerated in patients with advanced CRC undergoing liver surgery. EPA-FFA may have antiangiogenic properties. Remarkably, limited preoperative treatment may provide postoperative OS benefit. Phase III clinical evaluation of prolonged EPA-FFA treatment in CRCLM patients is warranted.

TRIAL IDENTIFIER

ClinicalTrials.gov NCT01070355.

Obesity in Tonga: A cross-sectional comparative study of perceptions of body size and beliefs about obesity in lay people and nurses

SUMMARY

BACKGROUND

Obesity is a major public health issue in Tonga, where prevalence is significantly higher than in Europe and North America. Obesity and its health-related complications are likely to increase as a result of western influences on diet and lifestyle. The aim of this study was to investigate perceptions of body size in Tongan lay people and nurses, and their beliefs about the causes of obesity and its consequences for health.

METHODS

A cross-sectional comparative study was conducted. Medical and surgical inpatients and outpatients were recruited from Vaiola Hospital in Tonga, over a 4 week period. Hospital nurses were included for comparison. Overall, 73 lay public and 34 nurses completed questionnaires about their beliefs about obesity, perceptions of their own body size and the health conditions associated with obesity. Subjects were also weighed and measured for calculating body mass index (BMI).

RESULTS

Both Tongan lay people and nurses underestimated their body weight and size, although the degree of underestimation was more marked in the lay group. The more accurate perception of body size in nurses may reflect their greater understanding of the health consequences of obesity.

CONCLUSIONS

This study has provided some insight into how obesity is viewed in Tonga, in particular differences between lay people and nurses in their own perception of weight, beliefs about obese people and the health consequences of obesity. Future research should aim to explore Tongans views of the health consequences of obesity as well as their perceptions of how serious these consequences are.

Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom

Obesity levels in the United Kingdom have risen over the years. Studies from the United States and elsewhere have reported variable outcomes for obese liver transplant recipients in terms of post-liver transplant morbidity, mortality, and graft survival. This study was designed to analyze the impact of the body mass index (BMI) on outcomes following adult liver transplantation. Data from 1994 to 2009 were retrieved from a prospectively maintained database. Patients were stratified into 5 World Health Organization BMI categories: underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-34.9 kg/m(2)), and morbidly obese (≥35.0 kg/m(2)). The primary outcome was an evaluation of graft and patient survival, and the secondary outcome was an assessment of postoperative morbidity. Bonferroni correction was applied with statistical significance set at P < 0.012. Kaplan-Meier curves were used to study the effects of BMI on graft and patient survival. A total of 1325 patients were included in the study: underweight (n = 47 or 3.5%), normal-weight (n = 643 or 48.5%), overweight (n = 417 or 31.5%), obese (n = 145 or 10.9%), and morbidly obese patients (n = 73 or 5.5%). The rate of postoperative infective complications was significantly higher in the overweight (60.7%, P < 0.01) and obese recipients (65.5%, P < 0.01) versus the normal-weight recipients (50.4%). The morbidly obese patients had a longer mean intensive care unit (ICU) stay than the normal-weight patients (4.7 versus 3.2 days, P = 0.03). The mean hospital stay was longer for the overweight (22.4 days, P < 0.001), obese (21.3 days, P = 0.04), and morbidly obese recipients (22.4 days, P = 0.047) versus the normal-weight recipients (18.0 days). There was no difference in death-censored graft survival or patient survival between the groups. In conclusion, this is the largest and only reported UK series on BMI and outcomes following liver transplantation. Overweight and obese patients have significantly increased morbidity in terms of infective complications after liver transplantation and, consequently, longer ICU and hospital stays.

The omega-3 polyunsaturated fatty acid eicosapentaenoic acid inhibits mouse MC-26 colorectal cancer cell liver metastasis via inhibition of PGE2-dependent cell motility

BACKGROUND AND PURPOSE

The omega-3 polyunsaturated fatty acid (PUFA) eicosapentaenoic acid (EPA) has antineoplastic activity at early stages of colorectal carcinogenesis, relevant to chemoprevention of colorectal cancer (CRC). We tested the hypothesis that EPA also has anti-CRC activity at later stages of colorectal carcinogenesis, relevant to treatment of metastatic CRC, via modulation of E-type PG synthesis.

EXPERIMENTAL APPROACH

A BALB/c mouse model, in which intrasplenic injection of syngeneic MC-26 mouse CRC cells leads to development of liver metastases, was used. Dietary EPA was administered in the free fatty acid (FFA) form for 2 weeks before and after ultrasound-guided intrasplenic injection of 1 × 10(6) MC-26 cells (n= 16 each group).

KEY RESULTS

Treatment with 5% (w w(-1)) EPA-FFA was associated with a reduced MC-26 mouse CRC cell liver tumour burden compared with control animals (median liver weight 1.03 g vs. 1.62 g; P < 0.034). Administration of 5% EPA-FFA was also linked to a significant increase in tumour EPA incorporation and lower intratumoural PGE(2) levels (with concomitant increased production of PGE(3)). Liver tumours from 5% EPA-FFA- treated mice demonstrated decreased 5-bromo-2-deoxyuridine-positive CRC cell proliferation and reduced phosphorylated ERK 1/2 expression at the invasive edge of tumours. A concentration-dependent reduction in MC-26 CRC cell Transwell® migration following EPA-FFA treatment (50-200 µM) in vitro was rescued by exogenous PGE(2) (10 µM) and PGE(1)-alcohol (1 µM).

CONCLUSIONS AND IMPLICATIONS

EPA-FFA inhibits MC-26 CRC cell liver metastasis. EPA incorporation is associated with a 'PGE(2) to PGE(3) switch' in liver tumours. Inhibition of PGE(2)-EP(4) receptor-dependent CRC cell motility probably contributes to the antineoplastic activity of EPA.

Repeat hepatic resection for colorectal liver metastases

BACKGROUND

Some 75-80 per cent of patients undergoing liver resection for colorectal liver metastases develop intrahepatic recurrence. A significant number of these can be considered for repeat liver surgery. This study examined the outcomes of repeat liver resection for the treatment of recurrent colorectal metastases confined to the liver.

METHODS

Patients who underwent repeat liver resection in a single tertiary referral hepatobiliary centre were identified from a database. Clinicopathological variables were analysed to assess factors predictive of survival.

RESULTS

A total of 195 patients underwent repeat resection between 1993 and 2010. Median age was 63 years, and the median interval between first and repeat resection was 13·8 months. Thirty-three patients (16·9 per cent) underwent completion hemihepatectomy or extended hemihepatectomy and the remainder had non-anatomical or segmental resection. The 30-day mortality rate was 1·5 per cent, and the overall 30-day morbidity rate was 20·0 per cent. Overall 1-, 3- and 5-year survival rates were 91·2, 44·3 and 29·4 per cent respectively. Tumour size 5 cm or greater was the only independent predictor of overall survival (relative risk 1·71, 95 per cent confidence interval 1·08 to 2·70; P = 0·021). Neoadjuvant chemotherapy before resection, perioperative blood transfusion, bilobar disease, R1 resection margin and multiple metastases were among factors that did not significantly influence survival.

CONCLUSION

Repeat hepatic resection remains the only curative option for patients presenting with recurrent colorectal liver metastases.

Performance and Quality Indicators: The Importance of Accurate Coding

Since the seminal work of Jarman et al in 1999, standardised mortality ratios have been published for all English hospitals in the NHS. These have been widely digested by the media, clinicians, managers and the public alike, with differences in mortality rates taken to represent variation in the overall quality of care provided by institutions. The appetite for comparative data has continued and a wealth of performance data is now made publicly available, be it from the department of Health, the Care Quality Commission, professional bodies maintaining their own specialty registries or from third-party agencies such as dr Foster.

Omega-3 polyunsaturated fatty acids for the treatment and prevention of colorectal cancer

Omega (ω)-3 polyunsaturated fatty acids (PUFAs) are naturally occurring substances that are well tolerated and have been used extensively for the prevention of cardiovascular disease. More recently, ω-3 PUFAs have been recognised to have anticancer activity. There is also evidence suggesting improved efficacy and/or tolerability of conventional cancer chemotherapy when administered with ω-3 PUFAs. The purpose of this review is to (i) describe the mechanisms by which ω-3 PUFAs are thought to have antineoplastic activity, (ii) review published preclinical and clinical studies that support anti-colorectal cancer activity and (iii) summarise current clinical trials investigating the potential therapeutic role(s) of ω-3 PUFAs at different stages of colorectal carcinogenesis, from adenoma (polyp) prevention to treatment of established malignant disease and prevention of cancer recurrence.

Transplantation of solid organs procured from influenza A H1N1 infected donors

Following the influenza A H1N1 (swine flu) pandemic, there remains little evidence informing the safety of transplanting organs from donors suspected or diagnosed with H1N1. Limited guidelines from the major transplant societies leave the use of such organs at the discretion of individual transplant centres, and practice varies considerably both nationally and internationally. We present the largest published series of outcome following transplantation of organs from H1N1 positive donors and demonstrate that these organs can be transplanted safely and with good short-term outcome. We discuss our local policy for treatment of recipients with Oseltamivir.

The impact of postoperative infection on long-term outcomes in liver transplantation

INTRODUCTION

Postoperative infection (POI) prolongs inpatient stay, delays return to normal activity, and may be detrimental to long-term survival after cancer resections. This study sought to identify the impact of postoperative infection on liver transplantation outcomes.

METHODS

We analyzed our prospective database of 910 adult patients who underwent liver transplantation between 2000 and 2010 in a single UK center. POI was defined as pyrexia plus positive cultures from blood, sputum, urine, wound, or ascitic fluid. Patient demographic features and perioperative variables were analyzed for their effects on POI. The impacts of POI on overall survival (OS) and graft survival were analyzed using Kaplan-Meier curves with log-rank tests for significance, before entry into a multivariate regression analysis. We analyzed the effects of POI on the length of hospital stay (LOS) and the incidence of acute rejection episodes and readmissions within 1 year as secondary outcomes.

RESULTS

Patients who developed a postoperative chest or wound infection showed poorer OS at a mean of 7.0 versus 8.8 years (P = .009) and 7.0 versus 8.8 years (P = .003), respectively. Infection in blood, ascitic fluid, or urine showed no significant impact on survival. LOS was significantly increased among patients with a wound (median 21 vs 17 days, P = .011), a sputum (median 24 vs 17 days, P < .001), or a blood infection (median 32 vs 17 days, P < .001). Higher rates of intraoperative blood transfusion were observed among subjects who developed a chest or a wound infection. There was no difference in other variables between those who did versus did not develop an infection. Upon multivariate analysis, wound infection was the strongest independent predictor of OS (P = .007).

CONCLUSION

We demonstrated that wound or chest infections were associated with poorer OS. More aggressive prophylactic and/or therapeutic interventions targeting specific sites of infection may represent a simple and cost-effective measure to reduce hospital stay and improve OS.

Randomized clinical trial of routine on-table cholangiography during laparoscopic cholecystectomy (Br J Surg 2011; 98: 362–367)

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Spontaneous resolution of pulmonary nodules in autoimmune pancreatitis

CONTEXT

Autoimmune pancreatitis is a rare benign disorder that can be confused with pancreatic cancer and the treatment pathway differs dramatically.

CASE REPORT

We present a unique case of pulmonary nodules associated with autoimmune pancreatitis, that was initially confused for pancreatic cancer which resolved spontaneously. Herein we describe the case and subsequent management and discuss the ever increasing incidence of autoimmune pancreatitis.

CONCLUSION

Pulmonary nodules associated with equivocal CT findings of primary pancreatic cancer should be treated with suspicion that the primary diagnosis may be incorrect and other differential diagnoses should be explored.

Index admission laparoscopic cholecystectomy for patients with acute biliary symptoms: results from a specialist centre

BACKGROUND

Index admission laparoscopic cholecystectomy (ALC) is the treatment of choice for patients admitted with biliary symptoms but is performed in less than 15% of these admissions. We analysed our results for ALC within a tertiary hepatobiliary centre.

METHODS

Data from all cholecystectomies carried out under the care of the two senior authors from 1998 to 2008 were prospectively collected and interrogated.

RESULTS

1710 patients underwent cholecystectomy of which 439 (26%) were ALC. Patients operated on acutely did not have a significantly different complication rate (P= 0.279; 4% vs.3%). Factors predicting complications were abnormal alkaline phosphatase (ALP) (P= 0.037), dilated common bile duct (CBD) (P= 0.026), cholangitis (P= 0.040) and absence of on table cholangiography (OTC) (P= 0.011). There were no bile duct injuries. Patients undergoing ALC had a higher rate of conversion to an open procedure (P < 0.001:10% vs.3%). The proportion of complicated disease was higher in the ALC group (P < 0.001; 70% vs.31%). Only complicated disease (P= 0.006), absence of OTC (P < 0.001) and age greater than 65 years (P < 0.001) were predictive of conversion on multivariate analysis.

CONCLUSIONS

Laparoscopic cholecystectomy can be performed safely in patients with acute biliary symptoms and should be considered the gold standard for management of these patients thus avoiding avoidable readmissions and life-threatening complications. A higher conversion rate to an open procedure must be accepted when treating more complicated disease. It is the severity of disease rather than timing of surgery which most probably predicts complications and conversions.

Predictors of blood transfusion requirement in elective liver resection

BACKGROUND

Liver resection remains major surgery frequently requiring intra-operative blood transfusion. Patients are typically over cross-matched, and with blood donor numbers falling, cross-matching and transfusion policies need rationalizing.

AIM

To identify predictors of peri-operative blood transfusion.

METHODS

A retrospective review of elective hepatic resections over a 4-year period was performed. Twenty-six variables including clinicopathological variables and intra-operative data were collated, together with the number of units of blood cross-matched and transfused in the immediate peri-operative period (48 h). Multivariate regression analysis was performed to identify independent predictors of blood transfusion, and a Risk Score for transfusion constructed.

RESULTS

Five hundred and eighty-nine patients were included in the study, and were cross-matched with a median 10 units of blood. Seventeen per cent of patients received a blood transfusion; median transfusion when required was 2 units. Regression analysis identified seven factors predictive of transfusion: haemoglobin <12.5 g/dL, pre-operative biliary drainage, coronary artery disease, largest tumour >3.5 cm, cholangiocarcinoma, redo resection and extended resection (5+ segments). Patients were stratified into high or low risk of transfusion based on Risk Score with a sensitivity of 73% [receiver-operating characteristic (ROC) 0.77].

CONCLUSIONS

Patients undergoing elective liver resection are over-cross-matched. Patients can be classified into high and low risk of transfusion using a Risk Score, and cross-matched accordingly.