Prediction of outcome following acute variceal haemorrhage

Between August 1979 and September 1982, acute variceal haemorrhage has been managed in the University Department of Surgery, Glasgow Royal Infirmary by a policy of oesophageal tamponade and injection sclerotherapy. Haemorrhage was controlled in 90% of admissions with an admission mortality of 28%. Recurrent haemorrhage occurred in half the patients surviving their first admission to hospital despite entering a programme of elective sclerotherapy. The results of this management policy are reviewed and the means of selecting patients for more aggressive therapy discussed. The deficiencies of a modified Child's classification in selection of patients are highlighted and overcome by the development of a prognostic index obtained by regression analysis on data collected on patients managed over this 3 year period. The admission prognostic index clearly defines 'high' and 'low' risk groups and 'predicts' outcome following admission in 90% of patients. The use of this index is validated in a further group of patients managed by a similar policy. Further regression analysis is used to obtain a prognostic index for alcohol cirrhotic patients alone and to determine the factors associated with one year survival. These indices are used to audit the management policy. Prothrombin, creatinine and encephalopathy are shown to have a clear association with outcome when measured at the time of variceal haemorrhage whereas other factors such as albumin and haemoglobin emerge as having prognostic value when measured one month following the acute episode. The possible applications of these prognostic indices are investigated in a prospective two centre study assessing the efficacy of propranolol in preventing recurrent variceal haemorrhage. It is shown that they can be used to exclude patients from entry into a study assessing the longterm benefit of propranolol when the prospects of short-term survival are limited. Their value in auditing management and their possible use in withdrawing treatment are shown. The prognostic indices are used to compare results of treatment at the two hospitals and are shown to be of value in analysing the results of the trial. These prognostic indices provide an objective means of evaluating patient management and may allow selection of patients for consideration of other treatment options

Needle Track Seeding of Primary and Secondary Liver Carcinoma After Percutaneous Liver Biopsy

Seeding of tumour in the needle track following percutaneous needle biopsy of liver neoplasms is rarely reported. We describe two such cases following the needle biopsy of an hepatocellular carcinoma and secondary colorectal carcinoma respectively. The risk of needle track recurrence of liver tumours should not be regarded as insignificant. The diagnosis of liver neoplasms may be achieved by non-invasive modalities, and their needle biopsy should be reserved for cases not amenable to surgical resection

Surgical management and longterm follow-up of non-parasitic hepatic cysts

BACKGROUND: Despite the increasing use of laparoscopic techniques, the optimal surgical approach for cystic liver disease has not been well defined. This study aims to determine the optimum operative approach for these patients. METHODS: Data were identified from the Lothian Surgical Audit, case note review and general practitioner contact. Patients were contacted and asked to complete the SF-36 questionnaire on quality of life. RESULTS: A total of 102 patients (67 with simple cysts, 31 with polycystic liver disease [PCLD], four with cystic tumours) underwent 62 laparoscopic deroofings, 15 open deroofings, 36 resections and one liver transplant between June 1985 and April 2006. The median follow-up was 77 months (range 3–250 months). Morbidity and recurrent symptom rates after laparoscopic surgery were greater in PCLD patients compared with simple cyst patients, at 31% (four patients) vs. 15% (seven patients) and 85% (11 patients) vs. 29% (24 patients), respectively. Four patients with simple cysts and eight with PCLD required further surgery. All patients with simple cysts had comparable quality of life after surgery. Patients with recurrent symptoms after surgery for PCLD had a significantly better quality of life following laparoscopic deroofing than after resection. CONCLUSIONS: Most simple cysts can be managed laparoscopically, but there is a definite role for open resection in some patients. Open deroofing is the preferred approach for a dominant cyst pattern in PCLD, whereas resection is necessary for diffuse cystic disease

Factors in perioperative care that determine blood loss in liver surgery

AbstractObjectivesExcessive blood loss during liver surgery contributes to postoperative morbidity and mortality and the minimizing of blood loss improves outcomes. This study examines pre- and intraoperative factors contributing to blood loss and identifies areas for improvement.MethodsAll patients who underwent elective hepatic resection between June 2007 and June 2009 were identified. Detailed information on the pre- and perioperative clinical course was analysed. Univariate and multivariate analyses were used to identify factors associated with intraoperative blood loss.ResultsA total of 175 patients were studied, of whom 95 (54%) underwent resection of three or more segments. Median blood loss was 782ml. Greater blood loss occurred during major resections and prolonged surgery and was associated with an increase in postoperative complications (P= 0.026). Peak central venous pressure (CVP) of >10cm H2O was associated with increased blood loss (P= 0.01). Although no differences in case mix were identified, blood loss varied significantly among anaesthetists, as did intraoperative volumes of i.v. fluids and transfusion practices.ConclusionsThis study confirms a relationship between CVP and blood loss in hepatic resection. Intraoperative CVP values were higher than those described in other studies. There was variation in the intraoperative management of patients. Collaboration between surgical and anaesthesia teams is required to minimize blood loss and the standardization of intraoperative anaesthesia practice may improve outcomes following liver surgery

Study protocol: HepaT1ca - an observational clinical cohort study to quantify liver health in surgical candidates for liver malignancies.

Background Accurate assessment of liver health prior to undertaking resectional liver surgery or chemoembolisation for primary and secondary cancers is essential for patient safety and optimal outcomes. LiverMultiScan™, an MRI-based technology, non-invasively quantifies hepatic fibroinflammatory disease, steatosis and iron content. We hypothesise that LiverMultiScan™can quantify liver health prior to surgery and inform the risk assessment for patients considering liver surgery or chemoembolization and seek to evaluate this technology in an operational environment. Methods/Design HepaT1ca is an observational cohort study in two tertiary-referral liver surgery centres in the United Kingdom. The primary outcome is correlation between the pre-operative liver health assessment score (Hepatica score - calculated by weighting future remnant liver volume by liver inflammation and fibrosis (LIF) score) and the post-operative liver function composite integer-based risk (Hyder-Pawlik) score. With ethical approval and fully-informed consent, individuals considering liver surgery for primary or secondary cancer will undergo clinical assessment, blood sampling, and LiverMultiScan™multiparametric MRI before and after surgical liver resection or TACE. In nested cohorts of individuals undergoing chemotherapy prior to surgery, or those undergoing portal vein embolization (PVE) as an adjunct to surgery, an additional testing session prior to commencement of treatment will occur. Tissue will be examined histologically and by immunohistochemistry. Pre-operative liver health assessment scores and the post-operative risk scores will be correlated to define the ability of LiverMultiScan™to predict the risk of post-operative morbidity and mortality. Because technology performance in this setting is unknown, a pragmatic sample size will be used. For the primary outcome, n = 200 for the main cohort will allow detection of a minimum correlation coefficient of 0.2 with 5% significance and power of 80%. Discussion This study will refine the technology and clinical application of multiparametric MRI (including LiverMultiScan™), to quantify pre-existing liver health and predict post-intervention outcomes following liver resection. If successful, this study will advance the technology and support the use of multiparametric MRI as part of an enhanced pre-operative assessment to improve patient safety and to personalise operative risk assessment of liver surgery/non-surgical intervention