Introduction: The Covid-19 pandemic in the UK quickly led to an overwhelming of the NHS from March 2020. This study investigates the impact of the Covid-19 pandemic on liver cancer surgical practice at a high volume Hepatobiliary unit. Methods: This is a retrospective analysis of prospectively collected database at St James's University Hospital, Leeds, UK. The unit activity from 15 months preceding and following the national lock down was analysed. Data analysed included indications, the number and extent of operations performed, resection margins, and post-operative complications. Results: There were 275 liver resections in the 15 months before lockdown and 280 after. The indications for liver resection were similar; colorectal liver metastases (64% versus 61%), hepatocellular carcinoma (12% versus 11%), cholangiocarcinoma (9% versus 8%), gallbladder cancer (2% versus 3%), non-colorectal liver metastases (7% versus 6%) and benign disease (6% versus 11%). Pre-lockdown, 32% of the resections performed were anatomical resections in comparison to 27% post-lockdown. Resection margins were not compromised, and complication rates were the same. The ongoing success of the ERAS programme was highlighted by the median time to discharge of five days in both groups. Conclusion: The general perception is that elective surgery has suffered during the pandemic. Whilst this is true with benign diseases and in some cancers, this study demonstrates that our unit maintained the number of liver resections and patient outcomes during the pandemic. This is due to highly motivated and flexible staff who demonstrated resilience and innovation to maintain a vital cancer surgery service.

Background: In recent years, there has been an increase in the use of graft from older donors and with higher BMI. There is a concern regarding the effect of this change in practice on the incidence of Early Allograft Dysfunction (EAD). Materials and Methods: Data regarding liver function, ischemic times, donor history and complications for all adults, elective, first liver transplant performed with whole grafts, in the last five years were extracted from a prospectively maintained database.EAD was defined according to Olthoff et al (bilirubin = 10mg/dL on day 7, INR = 1.6 on day 7, and ALT >2000 IU/L within the first 7 days). Results: 476 liver transplants met the criteria for this study; data analysis was performed for 100 transplants (77 DBDs, 23 DCDs) performed between September 2017 and 2018. Incidence of EAD was 30%, 24.7% in DBDs and 47.8% in DCDs (p=0.041).Donor BMI was significantly higher in the cases that developed EAD (28.6 vs 26.2, p=0.05) although this wasn't confirmed as significant risk factor in the univariate analysis. There was no significant difference in donor age between the 2 groups (47.1 vs 50.8, p=0.291) but a donor age above 61 years was a protective factor against the risk of EAD at the univariate analysis (p=0.032, RR=0.242).Other risk factors for EAD were, DCD graft (p=0.037, RR 2.798) and cold ischemia above 522 minutes (p=0.035, RR 3.185); while EAD increased the incidence of sepsis (p<0.001, RR=5.524), CVVH (p=0.022, RR= 3.879), graft loss (p=0.027, RR=6.8), recipient mortality (p=0.065, RR 5.231) and morbidity (p=0.08, RR 2.667). Conclusions: EAD can affect up to one third of liver transplant recipients and it can lead to sepsis, renal impairment and graft loss. More data are necessary to determine the role of donor age and BMI and other risk factors.

Background: Pioneered by the Mayo Clinic, multimodal therapy with neoadjuvant chemoradiotherapy (nCRT) and orthotopic liver transplant (OLT) has emerged as a promising option for unresectable hilar cholangiocarcinoma (hCCA), a disease otherwise associated with a dismal prognosis. Long-term outcome data is limited however, and concern exists surrounding reproducibility of results and justification of scare liver grafts. This study reports the experience of the Irish National Liver Transplant Programme with the Mayo Protocol.

Background: Since the advent of transjugular intrahepatic portosystemic shunts (TIPS), portosystemic shunt surgery (SS) has seldom been used in the management of portal hypertension, leading to an unclear role of SS in adult patients. Methods: All the patients who underwent SS between 1998 and 2016, and all the patients who underwent TIPS between 2008 and 2016 were included. Following retrospective data collection, the 10 patients in the SS group ware matched 1:2 with patients in the TIPS group based on demographics, presence of cirrhosis, Child-Pugh, MELD, and indication for procedure. Results: A total of 30 patients (mean age 57 years, 70% female) were involved in the study. The two groups were comparable for demographic characteristics, Child and MELD score; cirrhosis (p<0.001) was more common in the TIPS group, and portal vein thrombosis in the SS group (p=0.02). The main indication for the procedure was variceal bleeding in both groups. Procedure related mortality and morbidity were similar in the two groups (30% in the SS group vs 15% in the TIPS group and 30% vs 40% respectively, p=ns). At univariate analysis there was no difference in the risk for shunt dysfunction between the two groups; the only significant risk factor was the procedure being performed as an emergency (p=0.023, OR=11.3). Conclusion: SS can, in selected cases, achieve a similar rate of shunt patency and rebleeding rate compared to TIPS, with comparable mortality and morbidity. SS can be considered as a valid alternative to TIPS.

Background: The Mayo Clinic has reported a 5-year survival above 70% following neoadjuvant chemoradiation and liver transplantation for unresectable hilar cholangiocarcinoma (hCCA) . Despite these good Results it has not been widely accepted, mainly in Europe. Methods: All the patients affected by hCCA who underwent neoadjuvant treatment and liver transplantation from October 2004 to December 2016 were included in the study. Data were collected regarding patients characteristics, treatment related complications, recurrence and survival. Results: 26 patients with histologically proven, unresectable, hCCA (92% male, mean age 48 years) were included in the study, 24 patients (92%) had a hCCA on PSC. 6 patients (23%) required a Whipple at the time of the transplant and 4 (17%) required a redo transplant. All but 1 patient had a R0 resection, 9 patients (34.6%) had a residual tumor in the explanted liver. Surgical mortality and morbidity were 17% and 38%, respectively. The 3-year overall survival was 63.2% and the 5-year overall survival 51.6%. At the univariate analysis the presence of residual tumor in the explanted liver (p=0.011, OR=25) was the only identified risk factors for disease recurrence. Conclusion: Long term survival can be achieved in patients with unresectable hCCA using neoadjuvant chemoradiotherapy and liver transplantation with acceptable surgical mortality and morbidity. The presence of residual tumor in the explanted liver is a risk factor for disease recurrence.

Segmental duodenal resections (DR) have been increasingly performed for the treatment of primary duodenal tumours. The aim of the study is to review the indications for, clinical and operative details, and outcomes of patients undergoing elective DR.

Introduction. Exertional heatstroke with liver involvement is a rare and potentially fatal condition. In this setting, fulminant hepatic failure (FHF) occurs as a result of severe hypoxic hepatitis.Case Report. We report the case of a young male athlete who developed exertional heatstroke associated with rhabdomyolysis and hypoxic hepatitis while running the final stages of an ultra-marathon (62 km). The patient rapidly developed multiorgan failure, including fulminant hepatic failure, requiring intensive care admission for mechanical ventilation, hemodialysis, and inotropic support. He failed to improve with supportive measures and underwent an emergency hepatectomy followed by orthotopic liver transplant, after which he recovered completely.Conclusions. We discuss the rationale for liver transplantation in this setting, possible alternative treatments, and the pathophysiology of fulminant liver failure in this rare case.

Enteric fistulae represent a serious complication of abdominal surgery, associated with increased hospital stay and high postoperative morbidity and mortality. 1 Falconi M. Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut. 2001; 49: 2-10 PubMed Google Scholar , 2 Schecter W.P. Hirshberg A. Chang D.S. et al. Enteric fistulas: principles of management. J Am Coll Surg. 2009; 209: 484-491 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Moreover, when non-surgical management fails, reoperation is burdened with high morbidity and mortality. 1 Falconi M. Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut. 2001; 49: 2-10 PubMed Google Scholar , 2 Schecter W.P. Hirshberg A. Chang D.S. et al. Enteric fistulas: principles of management. J Am Coll Surg. 2009; 209: 484-491 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Therefore, a treatment that could shorten fistula closure time and avoid a second operation would be highly beneficial.

Context Benign/low malignant tumors or metastasis from renal cancer of the pancreatic head can be treated by enucleation; this procedure is technically demanding and it is often followed by high morbidity rates. Objective To analyze the peri-operative outcome of our series of enucleations for tumors of the pancreatic head. Methods From January 2010 to June 2012 29 out of 149 resected periampullary tumors were cystic neoplasms, 15 were neuroendocrine tumors (NET), 1 was metastasis from renal cancer and 1 was pseudopapillary solid tumor; in 13 of them (28% of 46 patients with pancreatic diseases eligible for atypical resection) an enucleation was performed. Enucleation was contraindicated when the lesion was deeply embedded in gland’s parenchyma involving Wirsung or originating from main pancreatic duct itself (main duct type IPMN), and in case of overt malignant appearance. We analyze the features of patients who underwent enucleation. Endoscopic ultrasound was performed preoperatively in 10 patients. ERCP with Wirsung stenting was realized when the distance between the main pancreatic duct and the lesion was less than 3 mm (4 cases). In patients submitted to stent positioning the mean distance between the lesion and the Wirsung duct was 1.9 mm while in the other group of patients it was 5 mm (P<0.05, t test). Intra-operative US was performed in all patients. At the end an absorbable fibrin sealant patch (Tachosil ® ) was placed on the area of enucleation. Results The mean diameter of the lesion was 1.9±1.1 cm (range: 1-4.5 cm); histology revealed 2 benign side branch IPMNs, 9 G1 NET, 1 metastasis from renal cancer and 1 pseudopapillary solid tumor. Mean operative time was 209.9±60.3 minutes and mean blood loss was 97.7±63.8 mL. No mortality was observed. Overall morbidity was 46% (including POPF rate of 31%): 4 POPF (2 grade B and 2 grade A). Mean length of hospital stay was 8.5±2.7 days. The reoperation rate was nihil. Readmission regarded only 1 patient. Conclusion Enucleation is a good alternative to pancreaticoduodenectomy in benign/low malignant tumors of the pancreatic head. Pre-operative Wirsung stenting, intra-operative ultrasounds and Tachosil ® application appear related to a satisfactory postoperative outcome.

Context Despite improvement in mortality, surgical morbidity in pancreatic surgery remains high, and infectious complications have a main role. Objective To evaluate the role of intra-operative bile culture as a guide for post-operative antibiotic therapy in case of infectious complications. Methods From January 2010 to June 2012 we realized 136 pancreatico­duodenectomies for periampullary diseases. Intra-operative bile sampling and postoperative sampling from peri-pancreatic drainage fluid for culture were performed in 110 patients (81%) who were enrolled in this study. Forty-four patients (40%) experienced infectious complications (Group A) while 66 patients (60%) did not (Group B). Infectious surgical complications were: 31 POPFs (13 grade A, 18 grade B-C), 6 abdominal abscesses, 5 biliary fistulas, 1 gastro-duodenal fistula and 19 wound infections (some patients has more than one complication). Data were collected prospectively. Results Bile cultures resulted positive in 61/110 patients (56%), there were no differences in the rate of infected bile between the two Groups (57% vs . 55%); preoperative biliary stenting was strongly correlated with biliary infection (100% in stented patients vs . 18% in non-stented; P<0.001). Drainage fluid cultures resulted positive in 66/110 (61%) patients: in Group A they were positive in 40/44 patients (91%) while in Group B in 26/66 patients (40%) (P<0.05, chi-square test). In Group A negative drainage cultures belonged to patients who developed grade A POPF or wound infection. In Group B positive drainage cultures belonged to patients with infected bile in 62% of cases; in 19% of cases cultures were contaminated by skin germs ( Staphylococcus ). From drainage fluid culture, we isolated 102 germs (55 Gram +, 41 Gram -, 8 fungi) in Group A and 37 germs (26 Gram +, 11 Gram -) in Group B; 44/102 germs (43%) and 12/37 germs (32%) in Groups A and B, respectively were identical to that found in bile cultures. Conclusion In patients who develop abdominal infectious complications the high concordance between bile and drainage fluid cultures suggests that bile cultures can be useful as a guide for postoperative antibiotic therapy. The presence of infected bile can cause contamination of peritoneal fluid even in uncomplicated patients but it has no clinical relevance.

Context Pancreaticoduodenectomy (PD) is still characterized by high morbidity rates even in high volume centers, mainly represented by postoperative pancreatic fistula (POPF) and its associated further consequences. Wirsung diameter and pancreatic texture are well known features related to increased POPF risk. However, limited information about the relationship between morphological features of pancreatic stump and POPF onset is available. Objective Aim of the study was to evaluate the relationship between pancreatic stump morphology, intra-operatively assessed, and the occurrence of POPF in patients undergoing PD in an high volume center. Methods Between January 2010 and June 2012 we performed 136 PDs for benign and malignant disease; in a subgroup composed by 72 cases we realized a prospective study recording intra-operative measurements of the remnant pancreatic stump, recording surgeon’s judgment about pancreatic texture, and highlighting the caliber of main pancreatic duct, its position and the whole area. Between March 2011 and June 2012, in a consecutive series of 72 PD, we prospectively recorded the following characteristics of the pancreatic stump: surgeon’s judgment about pancreatic texture, diameter of main pancreatic duct, the whole area of pancreatic section (approximately calculated as elliptic), the distance between Wirsung duct and cranio-caudal and antero-posterior margins. In all patients, post-operative complications were recorded. Results Pancreatic fistula occurred in 19 cases (23.8%), 10 of them clinically significant (grade B and C according to ISGPF classification). In univariate analysis, mean Wirsung diameter resulted significantly smaller in patients with POPF (3.18 vs . 4.48 mm; P=0.007) and in patients with clinically significant POPF (P=0.015); searching for a cut off value, Wirsung diameter smaller than 4 mm demonstrated an association with higher POPF incidence (37.5% vs . 4.35%; P=0.003). Similarly, soft pancreas texture resulted associated with an increasing POPF rate (75% vs . 7%; P<0.001). Analyzing pancreatic stump morphology, we observed a relationship between larger stump areas and POFP development (206 mm 2 in POPF cases vs . 131 mm 2 in patients without fistula; P=0.017); moreover, main pancreatic duct decentralization appeared significantly associated with a lower POPF risk (more evident on antero-posterior axis than on cranio-caudal; P=0.019 and P=0.144, respectively). In multivariate analysis, only pancreatic stump soft texture and Wirsung diameter smaller than 4 mm were associated with POPF. Conclusion This study confirms small Wirsung diameter and soft pancreatic texture as the main determinants for POPF development. Moreover, an higher risk of failure of pancreatic anastomosis is also observed in large pancreatic stumps and when main pancreatic duct is centrally located.