Abstract Background Hepatic vein involvement can be a contraindication to resection of liver tumours. This study aimed to assess the feasibility, long term outcomes and vein patency among patients who underwent hepatic vein reconstruction during liver resections for liver tumour(s). Methods Retrospective analysis of patients who underwent circumferential hepatic venous reconstruction identified from a prospectively maintained database. Standard volumetric analysis was performed using software to estimate volumetry with and without hepatic venous reconstruction. Long term vein patency was established using review of available radiology. Results 15 patients underwent 17 venous reconstructions for colorectal liver metastases (n=13), cholangiocarcinoma (n=1) and hepatocellular carcinoma (n=1). The median FLR without and with venous reconstruction were 32 (range 18.0-74.5) and 96% (range 26.9-97.7) respectively; the median increase in FLR was 34% per patient. Venous patency was 89% at a median follow-up of 25 months (Range 1-53) with 2 graft thrombosis. No patient developed PHLF. Conclusions Hepatic venous reconstruction during liver resection is safe and feasible. It has the potential to expand the scope of liver resection and preserve liver and venous drainage if needed in the future.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death, and its incidence is rising. Mortality from HCC is predicted to increase by 140% by 2035. Surveillance of high-risk patients with cirrhosis or chronic liver disease may be one means of reducing HCC mortality, but the level of supporting evidence for international guidelines is low/moderate. This study explores the real-world experience of HCC surveillance at a tertiary referral centre. Electronic patient records for all new HCCs diagnosed between August 2012 and December 2021 were retrospectively reviewed. Patient and tumour characteristics were evaluated, including the co-existence of chronic liver disease, cancer treatment and survival, and categorised according to HCC diagnosis within or outside a surveillance programme. Patients with HCC who presented through surveillance had smaller tumours diagnosed at an earlier stage, but this did not translate into improved overall survival. All patients in surveillance had chronic liver disease, including 91% (n = 101) with cirrhosis, compared to 45% (n = 29) in the non-surveillance cohort. We propose that the immune dysfunction associated with cirrhosis predisposes patients to a more aggressive tumour biology than the largely non-cirrhotic population in the non-surveillance group.

Summary Background Here we detail our experience of managing patients found to have a neuroendocrine neoplasm (NEN) whilst on immunosuppression for a transplanted organ. Aim We aimed to quantify the behaviour of NENs under solid-organ transplant-related immunosuppression. Design This was an observational, retrospective case series. Methods Ten patients were identified from a prospectively kept database. Three were excluded. Results Four patients received a liver, two a kidney, and one a heart transplant. All but one received calcineurin-based immunosuppression. NENs were found in five patients post-transplant: one had surgery for transverse colonic neuroendocrine carcinoma NEC (pT4N1M0, Ki67 60%), was cancer-free after four years; one had cold biopsy of duodenal NEN (pT1N0M0, Ki67 2%), cancer-free at four months; one 7 mm pancreatic NEN (pT1N0M0), untreated and stable for seven years; one small-bowel NEN with mesenteric metastasis (pTxNxM1), alive four years after diagnosis; and one untreated small-bowel NEN with mesenteric metastasis, stable at 1 year after liver transplantation. Two NENs were discovered pre-transplant, one pancreatic NEN (pT1N0M0, Ki67 5%), remains untreated and stable at three years. One gastric NEN (type 3, pT1bN0M0, Ki67 2%) remains stable without treatment for two years. Conclusions NENs demonstrate indolent behaviour in the presence of transplant-related immunosuppression.

Introduction Surveillance for hepatocellular cancer [HCC] in patients with cirrhosis is accepted practice with some evidence of benefit1. We assessed for differences in patients diagnosed through surveillance versus diagnosed outside surveillance. Methodology The hospital’s HCC database was interrogated for patients diagnosed with HCC between 2012 and 2021. Only patients diagnosed within our institute were included. Electronic medical records were retrospectively studied. Data included age, gender, aetiology of cirrhosis, Childs Turcott Pugh (CTP), date of HCC diagnosis, tumour size, AFP level, treatments, date of death, and date of last follow-up. Treatment interventions were classified as curative or non-curative. Liver transplant, resection, Ablation, and stereotactic ablative body radiotherapy [SABR] for small sized tumour lesions were termed curative. Survival analysis was carried out using Kaplan Meier method. Results 178 HCC patients were included. Mean age 65.3 years, 76% were male and 84% were Child Pugh A. 111 of 178 were diagnosed through surveillance (62.3%) while 67 patients (37.6%) were diagnosed through HCC related symptoms or incidentally. Mean age 64.4 (95% CI 62.1–66.7) and 66.9 (95%CI 63.6–70.2) years (P=0.045), 73% and 83.6% male, median AFP 6 (IQR 3–36) and 5 (IQR 3–37) IU/ML (P=0.805), mean size of the tumour 2.9 (95% CI 2.5–3.3) and 5.7 (95% CI 4.8–6.6) cm (P=0.000) between the two groups respectively. 33.3% vs 37.3% (P=1.000) received curative option, 66.7% vs 62.7% (P=1.000) received palliative treatment, 22% vs 18% lacked any form of treatment intervention. Survival at 1, 3 and 5 years was 87%, 54% and 43% in the surveillance group, and 75%, 50% and 34% in the non-surveillance group. 7.2% vs 58.2% (P=0.000) were non-cirrhotic in the surveillance and non-surveillance group. Conclusion Real world data from a single centre over a ten year period demonstrates that HCC surveillance leads to diagnosis of tumours at an earlier stage, as shown by average tumour size in this cohort. Despite similar demographics and rates of treatment between the two groups HCC surveillance does not appear to translate to a significant difference in overall survival. The majority of non-surveillance group having non-cirrhotic livers likely explains the parity in survival between the 2 groups. However, we plan to explore this further, to understand how best to optimise surveillance in HCC. References Harris PS, Hansen RM, Gray ME, Massoud OI, McGuire BM, Shoreibah MG. Hepatocellular carcinoma surveillance: An evidence-based approach. World J Gastroenterol. 2019;25(13):1550–1559. doi:10.3748/wjg.v25.i13.1550

Despite increasing complexity of surgery and patient age, the duration of hospital stay and mortality rate after pancreatoduodenectomy are decreasing. Understanding changes over time permits an estimation of a future surgical cohort in which complexity will increase. It is important that surgeons continue to push boundaries.

Abstract Background Patient selection for pancreatoduodenectomy (PD) is largely based upon local experience and established practice. This study sought to observe changes in complexity and patient cohort over time with the aim of predicting future cohort characteristic of patients undergoing PD. Methods All PDs at our institution between 1988 and 2020 were reviewed (n = 1,878) to observe changing trends in patient demographic, pathological diagnosis, operative factors and postoperative outcomes. Coefficients from regression models were reported as gradients per decade, to quantify the rate of change over time. The resulting models were then plotted to illustrate the trend across the study period, as well as forecasts for subsequent years. Results The annual volume (7 to 128) and proportion of pancreatic ductal adenocarcinoma (PDAC) (28 to 53%) increased at a linear rate. The proportion of associated vein resection (3 to 25%) and technical difficulty (type 2-4; 5 to 28%) increased in a nonlinear way, increasing more rapidly in later times. The average age (48 to 67) increased in a log linear trend. Length of stay reduced by 9.3%, whilst mortality reduced with an odds ratio of 0.69, per decade. Furthermore, When performance at our institution was compared to recently established benchmarks, it was shown that our institution regularly performed within these standards with few exceptions. By 2030 our predictions indicate that the average age will increase to 69, PDAC will comprise 62% of pathology, 40% will have an associated venous resection and 43% will be graded 2-4 in technical difficulty. Length of stay will have reduced to 9.6 days and mortality to 2%. Conclusions Despite increasing complexity of surgery and patient age, length of stay and mortality after PD are reducing. Understanding changes over time permits an estimation of a future surgical cohort where complexity will increase. It is important that surgeons continue to push boundaries. Patient selection, based upon prior experience may inhibit progression and development of services.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Background: Surgery in the form of hepatectomy remains the only curvative option for patients with intrahepatic cholangiocarcinoma (iCCA). However the long-term survival for iCCA patients following hepatectomy remains poor. We sought to develop a post-operative score to predict the patient survival following liver resection for iCCA and validate the score on a local population. Methods: The Surveillance, Epidemiology, and End Results (SEER) database identified patients with histologically confirmed iCCA between 1998 - 2013 as the derivation cohort. Prognostic factors were evaluated using Kaplan-Meier curves and Cox proportional hazards models. Primary end-points assessed in the study was overall Survival (OS). The score was externally validated upon a patient cohort from the United Kingdom. Results: The derivation cohort included 809 patients undergoing surgical resection for iCCA. Multivariate Cox regression model identified male (p=0.013), multifocal tumours (p<0.001), local invasion (p=0.027), vascular invasion (p=0.002), poor/anaplastic differentiation (p< 0.001), tumour size >5cm (p=0.013) and N classification (p<0.001) as prognostic factors. The corresponding c-statistic for the derived score was 0.71 (CI95: 0.67 - 0.76) for the derivation cohort and 0.80 (CI95%: 0.65 - 0.92) for the validation cohort (p=0.001). Conclusion: This novel risk score derived from a large national database, with external validation, may be useful in guiding post-operative management of patients following surgical resection for iCCA.

BACKGROUND:The aim of this study was to develop and validate a risk score to predict overall survival (OS) in patients undergoing surgical resection for hepatocellular carcinoma in non-cirrhotic liver (NC-HCC).METHODS:Patients who underwent resection for NC-HCC between 2004 and 2013 were identified from the SEER database. A derivation set of 75% of this cohort was used to develop a risk score. This was then internally validated on the remaining patients, and externally validated using a cohort of patients from The HPB Unit, Birmingham, UK.RESULTS:A total of 3897 patients were included from the SEER database, with a median post-diagnosis survival of 59 months. In the derivation set, multivariable analyses identified male sex, increasing tumour size, the presence of multiple tumours, bilobar tumours and major vascular invasion as adverse prognostic factors. A risk score generated from these factors was significantly predictive of OS, and was used to classify patients into low, medium and high-risk groups. These groups had a five-year OS of 69%, 51% and 19% in the internal, and 73%, 50% and 45% in the external validation sets.CONCLUSION:The proposed risk score is useful in the selection, pre-operative consenting and counselling of patients for surgery and to allow patients to make an informed decision regarding treatment.

Preservation of the future liver remnant (FLR) vascular integrity has always been considered crucial to achieving successful liver growths after major hepatectomies. Most surgeons appeared therefore reluctant to combine stage I of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with vascular reconstructions. Here we describe a case series, where we combine parenchymal transection and venous in- or outflow reconstruction of the FLR at stage I of ALPPS. In addition, the cold flush of the FLR or delayed portal vein embolization is applied in selected cases.

Background: Posthepatectomy liver failure (PLF) is one of the most feared complications in major hepatectomies. Elevated portal venous pressures (PVP) and flow (PVF) after resection are associated with development of PLF. Splenic artery ligation (SAL) is a potential strategy to modulate the portal venous inflow. The aim of our study is therefore to investigate the course of portal pressure and flows during major hepatectomy and the impact of SAL. Methods: All patients undergoing major hepatectomy on a non-cirrhotic liver were included in this prospective study since October 2017. Measurement of PVP and PVF were performed before and after liver resection a using Transit Time Flow Measurement (Medistim, Oslo, Norway). SAL was performed in patients with a Liver-remnant-to-Bodyweight-ratio (LR/BW-ratio) < 1%, or a PVP >5mmHg and/or suboptimal macroscopic liver parenchyma appearance, due to previous chemotherapy. Results: Sixteen cases were analysed with a median LR/BW-ratio of 1.2% (range 0.7-1.8%). Median PVP increased from 4 to 7 mmHg after resection, while PVF decreased from 851 to 710 ml/min. The peak lactate was higher in patients with an increase in PVP of >5mmHg (Figure 1). SAL effectively decreased the median PVP and PVF of 3 mmHg and 100 ml/min, respectively. Conclusion: Elevated pressures in the portal system have a negative impact on the initial function of the liver remnant after major hepatectomy. Splenic artery ligation appears easy to modulate the portal inflow. This study is currently recruiting further patients and the entire data set will be available at the conference.

Introduction: Hepatocellular carcinoma (HCC) is increasing in incidence in the UK and globally. Liver cirrhosis is the common cause for developing HCC. The common reasons for liver cirrhosis are viral hepatitis C (HCV), viral hepatitis B and alcohol. However, HCC caused by non-alcoholic fatty liver disease (NAFLD)-cirrhosis is now increasingly as a result of rising worldwide obesity. Aim: To compare the clinical presentation, treatment options and outcomes of HCC due to HCV and NAFLD patients. Methods: Data were collected from two liver transplant centres in the UK (Birmingham and Newcastle upon Tyne) between 2000 and 2014. We compared 275 patients with HCV-related HCC against 212 patients with NAFLD- related HCC. Results: Patients in the NAFLD group were found to be significantly older (P < 0.001) and more likely to be Caucasian (P < 0.001). They had lower rates of cirrhosis (P < 0.001) than those in HCV-HCC group. The NAFLD group presented with significantly larger tumours (P = 0.009), whilst HCV patients had a higher alpha fetoprotein (P = 0.018). NAFLD patients were more commonly treated with TACE (P = 0.005) than the HCV patients, whilst the HCV group were significantly more likely to be transplanted (P < 0.001). In patients selected for liver transplantation, 5-year survival rates in NAFLD were not significantly different from HCV-HCC (44 and 56% respectively, P = 0.102). Conclusion: In this study, NAFLD patients presented with larger tumours that were less likely to be amenable to curative therapy, as compared with HCV patients. Despite this disadvantage, patients with NAFLD had similar overall survival compared to patients with HCV.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

BACKGROUND:The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown.METHODS:This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft.RESULTS:A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis.CONCLUSION:In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

Aims: Metastases to the pancreas are rare and the outcomes after resection are unclear. The aim of this study is to evaluate mortality and survival associated with resection of metastases to the pancreas. Methods: Patients undergoing pancreatic resection for metastatic disease over a 16 year period (1997–2013) were identified from a prospectively maintained database. Information regarding the primary disease, nature of surgical resection, postoperative complications, pathological analysis and adjuvant chemotherapy were collected. Follow up details including development and management of recurrence and mortality were collected Results: 30 of 1438 pancreatic resections (2.1%) were for metastatic disease. The primary tumour was renal, colonic and melanoma in 23, 4 and 3 patients respectively. 13 patients had pancreaticoduodenectomy, 6 patients had total pancreatectomy for multifocal disease, 9 patients had distal pancreatectomy and splenectomy. There were 5 (16.6%) postoperative mortalities (<90 days). 9 patients received adjuvant chemotherapy. At last follow up 12 patients were alive, 4 with disease and 13 had died, 12 with disease. The overall and disease specific survival at 1, 5, 10 years are 73, 47, 23% and 91, 43, 33% respectively. Excluding post operative deaths, the median survival was 35.6 (95% CI = 0.0 - 76.0) months. Conclusions: Both the duration of survival and proportion of patients alive at key time points compare favourably to patients undergoing resection for primary pancreatic or periampullary malignancy. Resection of metastatic tumours to the pancreas should be considered when possible.