Background High intra-hepatic fat (IHF) content is associated with insulin resistance, visceral adiposity, and increased morbidity and mortality following liver resection. However, in clinical practice, IHF is assessed indirectly by pre-operative imaging [for example, chemical-shift magnetic resonance (CS-MR)]. We used the opportunity in patients undergoing liver resection to quantify IHF by digital histology (D-IHF) and relate this to CT-derived anthropometrics, insulin-related serum biomarkers, and IHF estimated by CS-MR. Methods A reproducible method for quantification of D-IHF using 7 histology slides (inter- and intra-rater concordance: 0.97 and 0.98) was developed. In 35 patients undergoing resection for colorectal cancer metastases, we measured: CT-derived subcutaneous and visceral adipose tissue volumes, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), fasting serum adiponectin, leptin and fetuin-A. We estimated relative IHF using CS-MR and developed prediction models for IHF using a factor-clustered approach. Results The multivariate linear regression models showed that D-IHF was best predicted by HOMA-IR (Beta coefficientper doubling: 2.410, 95% CI: 1.093, 5.313) and adiponectin (βper doubling: 0.197, 95% CI: 0.058, 0.667), but not by anthropometrics. MR-derived IHF correlated with D-IHF (rho: 0.626; p = 0.0001), but levels of agreement deviated in upper range values (CS-MR over-estimated IHF: regression versus zero, p = 0.009); this could be adjusted for by a correction factor (CF: 0.7816). Conclusions Our findings show IHF is associated with measures of insulin resistance, but not measures of visceral adiposity. CS-MR over-estimated IHF in the upper range. Larger studies are indicated to test whether a correction of imaging-derived IHF estimates is valid.

Introduction:Although the laparoscopic approach to distal pancreatectomy for benign and malignant diseases is largely replacing open surgery in some centers, well-designed studies comparing these approaches are limited. We present a case-matched study that compares the outcomes of laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP).Methods:Of 112 patients (51 female) who underwent surgery between January 2002 and December 2011, 44 patients were matched on a 1:1 basis (22 LDP, 22 ODP) according to age, sex, and tumor size. Outcomes were compared on an intention-to-treat basis. Data shown represent median where appropriate.Results:The laparoscopic and open groups were comparable for age (57 vs. 59.9 y, P=0.980), sex distribution (P=1.000), tumor size (3 vs. 4 cm, P=0.904), and the frequency of benign versus malignant disease (P=0.920). LDP was associated with significantly lower blood loss (100 vs. 500 mL, P=0.001), higher spleen preservation rate (45% vs. 18%, P=0.029), as well as shorter high dependency unit stay (1 vs. 5 d, P=0.001) and postoperative hospital stay (5 vs. 14 d, P=0.017). There was no significant difference in operating time (245 vs. 240 min, P=0.602) and postoperative morbidity (13.6% vs. 27.2%, P=0.431). In patients with malignant disease, there were no differences in R-0 resection margin status (90% vs. 85.7%, P=0.88), the numbers of lymph nodes retrieved (12.7 vs. 14.1, P=0.82), the 1- and 2-year survival rates (89% vs. 81%, P=0.54 and 74.2% vs. 71.5%, P=0.63, respectively), and the mean duration of survival (45 vs. 31 mo, P=0.157).Conclusions:The laparoscopic approach to distal pancreatectomy offers advantages over open surgery in terms of reductions in operative trauma and duration of postoperative recovery without compromising the oncologic resection.

Objectives Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity. This trial compared the effects of perioperative enteral immunonutrition (EIN) versus standard enteral nutrition (SEN) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.Methods Thirty-seven patients were randomized (EIN, n = 17; SEN, n = 20) to receive feed for 14 days preoperatively and 7 days postoperatively. Mediators of systemic immunity (interleukin 1, tumor necrosis factor , lymphocytes subsets, and complement components) and of mucosal immunity in duodenal biopsies, nutritional markers and parameters were evaluated.Results The groups were comparable for demographics, the concentrations of mediators of systemic and mucosal immunity at time of recruitment, and for the duration and amount of feed received. Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor and total hemolytic complement. Enteral immunonutrition-fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients.Conclusions The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.

Excess adiposity is an established risk factor for incident colorectal cancer (CRC) but whether this association extrapolates to poorer survival is unclear. We undertook a systematic review to examine relationships between measures of adiposity and survival in patients with CRC. For distinction, we included pre-diagnosis exposure and CRC-related mortality. We performed dose-response meta-analyses and assessed study quality using eight domains of bias. Six study categories were identified based on (i) timing of adiposity measurement relative to survival analysis time zero and (ii) clinical setting. Several types of adiposity measurements were reported; body mass index (BMI) was the commonest. For pre-diagnosis cohorts, baseline BMI negatively impacted on CRC-related mortality in men only (risk estimate per 5 kg m(-2) = 1.19, 95% confidence intervals: 1.14-1.25). The other groups were pre-diagnosis BMI but diagnosis as time zero; population-based cohorts; treatment cohorts; observational analyses within adjuvant chemotherapy trials; patients with metastatic CRC - each had several biases (e.g. treatment selection, reverse causality) and sources of confounding (e.g. chemotherapy 'capping'). Overall, there was insufficient evidence for a strong link between adiposity and survival. These findings demonstrate an important principle: an established link between an exposure (here, adiposity) and increased cancer incidence does not necessarily extrapolate into an inferior post-treatment outcome.

Aims: The aims of this study were to compare the diagnostic performance of CT scan, MR liver, PET-CT and intra-operative ultrasound (IOUS) for the detection of liver metastases against the histopathological findings, and to compare PET-CT with CT for the detection of distant disease in metastatic colorectal cancer patients eligible for surgical treatment.Methods: A prospective study was performed that measured concordance between the number and stage of metastatic lesions identified with various preoperative imaging modalities and histology of patients undergoing surgical treatment for CRLM.Results: Compared with histopathology, concordance for the number of metastatic liver lesions was moderate for CT scan (K = 0.477, 95% CI: 0.28-0.66), moderate for MR scan (K = 0.574, 95% CI: 0.39-0.75), good for FDG PET-CT (K = 0.703, 95% CI: 0.52-0.87) and very good for IOUS (K = 0.904, 95% CI: 0.81-0.99). Additional CRLM were identified intraoperatively in six patients (9.1%) with IOUS and in 7.5% of the cases surgical strategy was changed according to the new intraoperative findings. The diagnosis of ultra abdominal lymph node metastatic disease was made with PET-CT only in nine patients (13.6%)Discussion: Our study supports the recent recommendations of the Oncosurg Multidisciplinary International Consensus regarding the importance of high quality CT and MR in the staging of CRLM but provides further evidence for the added value of PET-CT, especially in detecting extrahepatic intra-abdominal metastatic disease that may be amenable to potentially curative resection. Despite these advances in preoperative staging, there still remains a role for IOUS in detecting additional metastases at the time of surgery. (C) 2014 Elsevier Ltd. All rights reserved.

Anti-Sm antibodies are intrinsically associated with systemic lupus erythematosus. The major targets are the so-called B and D polypeptides. The number of Sm targets increased upon the report that SDS–PAGE conditions could be manipulated to display not one, but three Sm-D polypeptides. To characterize the relative reactivities of Sm-D1, Sm-D2, and Sm-D3, both human and murine autoantibodies were screened. These sera displayed two distinct patterns of reactivity. The Sm-D1/D3 pattern was at least four times more common than Sm-D1/D2/D3 recognition. The predominant immunoreactive protein was Sm-D1. We screened over 40 monoclonal antibodies that were derived from MRL mice and were selected as anti-Sm positive. Of these, 27 reacted with at least one Sm-D polypeptide by protein blot, but in contrast to the MRL sera, none of these antibodies reacted with Sm-D2. Rather, there were two recognition patterns of approximately equal abundance, against Sm-D1/D3 or Sm-D1 alone. Last, we explored the immune response to isolated Sm-D (containing all three D antigens) from rabbit thymus. The autoantibody produced reacted only with Sm-D2. There is accumulating evidence that the anti-Sm response is at least partially antigen-driven. The details of the intragroup relationships within the Sm-D family of proteins provide further insight into the Sm autoimmune response.

This project aims to assess the impact of the introduction of a hepatobiliary and pancreatic (HPB) Quality Improvement Program (QIP) on postoperative complications following liver, biliary and pancreatic surgery. A prospective analysis of postoperative complications over a six month period was performed. Complications were analysed and graded according to internationally agreed definitions. Justification was sought and errors identified. Weekly meetings were performed to review each complication enabling an action plan to be created to prevent future recurrence. Rates were compared with previously audited and published results, using the chi-square test. A total of 326 procedures were performed over the six months including 30 pancreatectomies, 45 liver resections and 251 other procedures. 37 patients developed complications (11.3%) with 47 complications in total including two deaths. Using the ISGPS grading, eight complications were identified; two grade A, four grade B and two grade C. There were three grade A ISGLS complications and one grade B. 30 complications were justified as unavoidable, 16 as avoidable and one as indeterminate. Action plans included continued monitoring (n=41), formulation of new policy (n=3), individual counselling (n=4), educational offering (n=4). When compared with 2010 complication rates, 114 complications occurred in 233 liver operations during the baseline period, compared with 17 complications in 45 liver operations during the QIP period, OR=0.63 (95% CI: 0.33 to 1.22), p=0.17 and 86 complications occurred in 99 pancreatic resections during the baseline period, compared with 20 complications in 30 pancreatic resections during the QIP period OR=0.30 (95% CI: 0.12 to 0.79), p=0.01 The HPB QIP is a rigorous approach to grade every complication and death. A statistically significant reduction in pancreas related complications has already been obtained. Further work is required to determine the persistence and magnitude of this quality improvement.

AIMS:The high objective response rate to cetuximab along with chemotherapy in patients with colorectal liver metastases makes it an effective downsizing protocol to facilitate surgery in those with initially unresectable disease. Adoption of this strategy has been variable in the UK. A retrospective observational study was conducted in 7 UK specialist liver surgical centres to describe the liver resection rate following a downsizing protocol of cetuximab and chemotherapy and to evaluate the quality and efficiency of processes by which the treatment was provided.METHODS:Data were collected in 2012 by reviewing medical records of patients with colorectal metastases confined to the liver, defined as unresectable without downsizing therapy at first review by a specialist Multi Disciplinary Team (MDT).RESULTS:Sixty patients were included; 29 (48%) underwent liver resection following cetuximab and chemotherapy. Of the 29, 17 (59% or 28% of all patients) achieved R0 resection and 7 (24% or 12% of all patients) R1 resection. All treated patients were KRAS wild-type.CONCLUSION:In specialist liver surgical centres, where patients are evaluated for liver resection, optimal management by MDT using KRAS testing, cetuximab and chemotherapy results in a 28% R0 resection rate in patients with initially unresectable colorectal cancer liver metastases.

Introduction The laparoscopic approach to distal pancreatectomy for benign and malignant diseases appears to offer advantages and is replacing open surgery in some centres. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution study comparing the outcomes of LDP to ODP. Methods The demographic details, clinical characteristics and outcomes of patients who underwent laparoscopic distal pancreatectomy were compared to those who had the surgery performed by open technique. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 2002 and 2009, 32 patients (20 female) underwent 16 LDP and 16 ODP respectively. The laparoscopic and open groups were comparable for age (57 vs 63 years, p=0.584), sex distribution and tumour size (3.9 vs 4 cm, p=0.939). Both groups had a comparable number of malignant cases (56% vs 50%, p=1.0). Although LDP took longer to complete (287.5 vs 240 min, p=0.061), it was associated with significantly lower blood loss (300 vs 500 ml, p=0.031) but comparable perioperative transfusion rate (p=0.471). The laparoscopic approach was associated with a significantly higher spleen-preservation rate (overall: 50% vs 12.5%, p=0.05; benign pathology: 85.7% vs 25%, p=1.0). LDP patients had a significantly lower HDU stay (1 vs 4.5 days, p<0.001) and a significantly lower postoperative hospital stay (6.5 vs 13.5 days, p=0.001). There was no significant difference in the postoperative morbidity and the R0 resection margin status. Conclusion The laparoscopic approach to distal pancreatectomy results in significantly lower blood loss, and shorter HDU and hospital stay compared with open surgery. The postoperative morbidity and R0 resection margin rates were comparably similar. Competing interests None declared.

Background: With the expanding geriatric population, cancer prevalence in the elderly has increased accordingly. Within the oncogeriatric surgical population, it is of paramount importance to differentiate between frail and non-frail patients in order to tailor to each individual, the appropriate treatment, and to offer a more precise informed consent on risks and prognoses. The Comprehensive Geriatric Assessment (CGA) is extremely time consuming when administrated to each patient. Therefore, it is necessary to find a time-saving and efficient screening tool to assess the probability of developing postoperative complications in elderly cancer patients, and to anticipate the postoperative outcome. The aim of this study was to determine the prognostic ability of timed "Up & Go" (TUG) , Vulnerable Elders Survey (VES13) and Groningen Frailty Indicator (GFI) , with regard to short term postoperative complications in hepato-pancreato-biliary(HPB) oncogeriatric surgical patients.

A 48-year-old woman presented with chest symptoms. Multiple lesions seen on chest imaging were found to be pulmonary chondromas following surgical resection. Whole body magnetic resonance scan performed to investigate the possibility of Carney triad demonstrated a gastric lesion. This was resected and found to be a gastrointestinal stromal tumor. No evidence of paragangliomata was found on imaging. A diagnosis of incomplete Carney triad was made. Carney triad is a rare multiple neoplastic association of pulmonary chondroma, gastrointestinal stromal tumor, and paraganglioma. At least 2 tumors are required for diagnosis. Most patients are young women. No genetic cause has been identified. Management involves surgical resection of tumors and follow-up for recurrence and investigation for other elements of the triad.

s / Pancreatology 12 (2012) e1–e8 e6 reviewed for information on medications prior to diagnosis. Odds ratios, plus 95% CI, for the development of pancreatic cancer, were estimated using unconditional logistic regression. Results: 276 cases (median age1⁄471 years, range 48-99 years, 53% women) and 402 controls were identified. 19.5% of the cases also had diabetes. In the general study population, the risk of pancreatic cancer with regular statins use was reduced (OR1⁄40.67, 95% CI1⁄40.44-1.03, p1⁄40.07). In diabetics, the risk was further reduced (OR1⁄40.38 95% CI 0.12-1.20. p1⁄40.10). Conclusions: This preliminary data showed statin use reduces the risk of pancreatic cancer in the general study population and in type 2 diabetics. The study will progress to more precisely define the effect size, but may support the use of statins for chemoprevention in diabetics Take-home message: Preliminary results from this two centre, casecontrol study, support the hypothesis of a protective effect for statins in the development of pancreatic cancer in type 2 diabetics. As such theremay be a role for statins in chemoprevention in this at risk group

Liver cysts are common,affecting 5%-10% of the population.Most are asymptomatic,however 5% of patients develop symptoms,sometimes due to complications and will require intervention.There is no consensus on their management because complications are so uncommon.The aim of this study was to perform a collected review of how a series of complications were managed at our institutions.Six different patients presenting with rare complications of liver cysts were obtained from Hepatobiliary Units in the United Kingdom and The Netherlands.History and radiological imaging were obtained from case notes and computerised radiology.As a result,1 patient admitted with inferior vena cava obstruction was managed by cyst aspiration and lanreotide;1 patient with common bile duct obstruction was first managed by endoscopic retrograde cholangiopancreatography and stenting,followed by open fenestration;1 patient with ruptured cysts and significant medical co-morbidities was managed by percutaneous drainage;1 patient with portal vein occlusion and varices was managed by open liver resection;1 patient with infected cysts was treated with intravenous antibiotics and is awaiting liver transplantation.The final patient with a simple liver cyst mimicking a hydatid was managed by open liver resection.In conclusion,complications of cystic liver disease are rare,and we have demonstrated in this series that both operative and non-operative strategies have defined roles in management.The mainstays of treatment are either aspiration/sclerotherapy or,alternatively laparoscopic fenestration.Medical management with somatostatin analogues is a potentially new and exciting treatment option but requires further study.

Introduction While large and persistent pancreatic pseudocysts are amenable to internal drainage by laparoscopic techniques, the benefits of this minimally invasive approach remain to be demonstrated. The aim of this study was to compare the open and laparoscopic approaches for internal drainage of large and persistent pancreatic pseudocysts. Methods Patients who underwent cystgastrostomy were selected, and the demographic features, clinical characteristics and outcomes of those who had the surgery performed laparoscopically were compared to those who had open surgery. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 1997 and 2010, 42 patients (15 female and 27 male) underwent 45 surgical internal drainage procedures for pancreatic pseudocysts (36 laparoscopic with two conversions to open surgery, and nine open). The laparoscopic and open groups were comparable for age (56 vs 53 years, p=0.448), sex distribution, and size of pseudocyst (12 vs 13 cm, p=0.305). The two approaches had comparable operating times (90 vs 75 min, p=0.630) but laparoscopic surgery carried a significantly lower risk of postoperative morbidity (5.8% vs 54.5%, p=0.001) and shorter postoperative hospital stay (2 vs 10.5 days, p<0.001). Laparoscopic surgery was also associated with a more rapid resumption of dietary intake (median 4 vs 6 days, p=0.065). There was one death in the open group (11.1%) but none in the laparoscopic group. Conclusion The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a smoother and more rapid recovery and a shorter hospital stay compared with open surgery. Competing interests None declared.