An investigation of the detection and treatment of colorectal liver metastases

In the United Kingdom, colorectal cancer creates a significant health burden, with over 34 000 new cases diagnosed each year and over 16 000 deaths per year. Almost 50% of patients with colorectal cancer will develop liver metastases: up to 25% will have liver metastases at time of initial presentation with the remaining 25% developing liver metastases during the course of their disease. Death from hepatic metastases accounts for a large percentage of colorectal cancer mortalities and if left untreated the prognosis is poor, with median survival from 5 to 21 months with almost none alive at 5 years. Surgical resection offers the only potential curative treatment for colorectal liver metastases with the five year survival rate varying in the literature from 25% to 51%. Hepatic surgery was associated with high morbidity and mortality and it is only since the 1990s that an evidence base has been published showing improved long term outcomes. Radiological imaging plays an essential role in the detection and characterisation of colorectal liver metastases. Accurate staging of the disease allows patient selection for hepatic surgery. Despite recent and significant technological advances in radiological imaging, up to 50% of patients that have undergone curative partial hepatectomy will develop hepatic recurrence in the first two years after surgery. Evidence from growth rate studies has shown that colorectal liver metastases are slow growing and that these recurrences were present at the time of initial staging. Therefore, the problem of occult liver metastases remains. This thesis has assessed the potential clinical role of a new imaging modality in the detection of colorectal liver metastases: contrast enhanced ultrasound (CE-US). Initially a prospective trial using percutaneous CE-US with intravenous administration of an ultrasound contrast agent that has been used primarily in cardiac imaging was performed. The results of this study found that CE-US enhanced late phase vascular imaging. This is an important finding as the persistence of a hypoechoic liver lesion in to the late phase of CE-US imaging is typical of a colorectal liver metastasis and an agent that optimises the late phase would allow improved characterisation of colorectal liver metastases. As a result, CE-US was then compared to percutaneous unenhanced ultrasound and found to have improved sensitivity and accuracy in the detection of colorectal liver metastases (sensitivity 100%, accuracy 90.8% versus 64.4% and 64.4% respectively). Furthermore, the optimal late phase imaging was achieved by the lowest dose of agent (0.4mL) that would allow repeated injections if incorporated into routine clinical practice. These findings support the growing evidence base for percutaneous CE-US and it is likely that CE-US will replace unenhanced ultrasound in routine clinical practice. (Abstract shortened by ProQuest.)

The virtual uncertainty of futility in emergency surgery

No abstract available

Poor outcomes in patients with sepsis undergoing emergency laparotomy and laparoscopy are attenuated by faster time to care measures

ACKNOWLEDGEMENTS NE received the University of Aberdeen Innes Will Endowed Research Scholarship 2022 to carry out the research. FUNDING INFORMATION The Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) is a Scottish Government initiative supported via the Modernising Patient Pathways Programme (MPPP).Peer reviewedPublisher PD

Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology

Aim: Variation in major gastrointestinal surgery rates in the older population suggests heterogeneity in surgical management. A higher prevalence of comorbidities, frailty and cognitive impairments in the older population may account for some variation. The aim of this study was to determine surgeon preference for major surgery versus conservative management in hypothetical patient scenarios based on key attributes.Method: A survey was designed according to the discrete choice methodology guided by a separate qualitative study. Questions were designed to test for associations between key attributes (age, comorbidity, urgency of presentation, pathology, functional and cognitive status) and treatment preference for major gastrointestinal surgery versus conservative management. The survey consisting of 18 hypothetical scenarios was disseminated electronically to UK gastrointestinal surgeons. Binomial logistic regression was used to identify associations between the attributes and treatment preference.Results: In total, 103 responses were received after 256 visits to the questionnaire site (response rate 40.2%). Participants answered 1847 out of the 1854 scenarios (99.6%). There was a preference for major surgery in 1112/1847 (60.2%) of all scenarios. Severe comorbidities (OR 0.001, 95% CI 0.000–0.030; P = 0.000), severe cognitive impairment (OR 0.001, 95% CI 0.000–0.033; P = 0.000) and age 85 years and above (OR 0.028, 95% CI 0.005–0.168; P = 0.000) were all significant in the decision not to offer major gastrointestinal surgery.Conclusion: This study has demonstrated variation in surgical treatment preference according to key attributes in hypothetical scenarios. The development of fitness-stratified guidelines may help to reduce variation in surgical practice in the older population

Barriers and facilitators to deliberate practice using take-home laparoscopic simulators

This research was funded by The Association for the Study of Medical Education and the UK General Medical Council (Excellent Medical Education Joint Award). Open Access via Springer Compact AgreementPeer reviewedPublisher PD

Frailty in older patients undergoing emergency laparotomy

Objective: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. Summary Background Data: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. Methods: An observational multicenter (n=49) UK study was performed (March–June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5–7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. Results: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24–8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26–16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. Conclusions: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies

The Clinical Frailty Scale : estimating the prevalence of frailty in older patients hospitalised with COVID-19. The COPE study

Acknowledgments: The COPE study collaborators.Peer reviewedPublisher PD

The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population : a multicentre study

Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.Peer reviewedPostprin

Prevalence of multimorbidity and its association with outcomes in older emergency general surgical patients : an observational study

Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.Peer reviewedPublisher PD