6-monthly ultrasound surveillance is recommended in cirrhotic patients at risk of HCC. The benefit of surveillance has never been demonstrated in a western population.
Methods
A retrospective, single centre cohort analysis in patients diagnosed with HCC from 2008–2013. From 2008 an automated recall system for 6-monthly ultrasound was instigated by the radiology department, in preference ad hoc ultrasound requests. Patients with abnormal lesions proceeded to CT, MRI or liver biopsy according to defined international criteria. The primary end-points evaluated were stage of cancer detection (early i.e. BCLC 0 or A), versus late presentation (BCLC B-D) and patient survival from time of diagnosis to 12 months and 60 months.
Results
160 patients were identified. Surveillance status was known in 132 patients. Median patient age was 68 years (57–75), median number of lesions was one, diameter of largest lesion 30 mm (19–50), and AFP 19.5 (5–250). Patients under surveillance were more likely to have disease at a curative stage 67 vs. 39% (p = 0.006, OR 0.59 (0.41–0.84), and had better survival at 1 year 80 vs. 62% (p = 0.04, OR 0.77 (0.62–0.97), and at 5 years 60 vs. 41% (p = 0.046, OR 0.69 (0.48–0.98). On univariate analysis the following variables on survival were evaluated: Age (p = 0.11), Number HCC nodules (p = 0.31), Total diameter of lesions (p = 0.001), Diameter of largest lesion (p < 0.001), AFP (p < 0.001). The presence on imaging of extra-hepatic metastases (p = 0.006), lymph nodes (p = 0.004), and portal vein thrombosis p < 0.001), were associated with poorer survival.
Conclusion
Surveillance for hepatocellular carcinoma leads to earlier diagnosis and improved survival.
Traditionally plastic stents (PS) are inserted at the index ERCP to treat obstructive jaundice from malignant distal biliary strictures. However, with the development of fully covered metal stents (C-SEMS), this approach is now debated and practise at the Royal Liverpool Hospital (RLH) has now changed towards preference for C-SEMS in this clinical scenario. This of course has cost implications as C- SEMS are 15–20 times more expensive than plastic stents. The aim of this study is to determine the benefit of C-SEMS over PS placement, to answer the question which stent should be inserted at the index ERCP if a patient presents with malignant obstructive jaundice
Methods
A retrospective audit was performed of patients undergoing ERCP with placement of plastic or SEMS for obstructive jaundice due to malignant distal biliary strictures at the RLH between March 2007 and December 2012. Clinical history, course and outcomes from MDT documents, electronic patient records and the endoscopy database were recorded on a standardised proforma. Only PS and C-SEMS insertion at the index ERCP were included.
Results
Of 147 patients identified, 72 were excluded (bare metal stents or partially covered metal stents placed). This left 43 in PS group and 32 in C-SEMS group. 21 patients underwent surgical resection; 17 within PS and 4 within C-SEMS. Of these no patient with C-SEMS but 3 (18%) patients with plastic stents required re-intervention prior to surgery due to stent dysfunction. In the remaining palliative patients (PS: n = 26 and C-SEMS: n = 28), 19 with plastic stents (73%) and 3 patients with SEMS (7%) required endoscopic re-intervention due to stent dysfunction (p < 0.001). Median time to re-intervention was 32 days (range 5–58) for PS and 25 days (range 25–38.5) for C-SEMS (p = 0.394). Overall, PS at the index ERCP only offered definitive stenting in only 53% (23/43) compared to 91% (29/32) by C-SEMS (p = 0.001).
Conclusion
Placement of a fully covered SEMS (C-SEMS) at index ERCP offered a definitive procedure in majority of patients compared to plastic stent (PS) which was just over half. Whilst C-SEMS significant more expensive than PS, this increased cost may be potentially be offset by the reduction in the need for repeat ERCP intervention and subsequent stent insertions. A full cost analysis is currently being undertaken.
The ideal management of variceal bleeding in the setting of acute alcoholic hepatitis is unclear. We present the outcome of this subgroup of patients in a cohort of patients treated with primary TIPS for variceal bleeding.
Methods
A retrospective analysis on patients who had TIPS procedure performed as a primary treatment modality within 72 h of acute variceal bleeding from December 2010 to April 2013 with a minimum of 6 months follow up was performed.
Results
56 patients were included into the final analysis. In AH patients (n = 18) mean age was 48 years (30–65), mean discriminant function (DF) was 51 (24–87) and mean MELD score was 22. The 6 month mortality was 50%(9/18) with (7/9) dying within 30 days. The median HVPG (mmHg) pre-TIPS and post-TIPS were 16.5 and 6.5 respectively. In non-AH patient (n = 38) average age was 51y (25–70) mean MELD score was 14 (22–7). The mortality was 13% (5/38) at 6 months, (3/5) died by day 30. The median HVPG (mmHg) pre-TIPS and post-TIPS was 23 and 10 respectively.
Conclusion
In patients with variceal bleeding complicating AH there is a higher 30 day and 6 month mortality in patients managed with a primary TIPS in comparison to patients with cirrhosis. The ideal management of this complex group remains unclear.
Poster: ECR 2014 / C-1772 / Does a pancreatic necrosectomy tubogram detect additional clinically significant information compared to computerised tomography? by: Dhandapani, R. Wiles, J. Evans; Liverpool/UK
Objective: To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. Background: The optimal management of severe pancreatic necrosis is evolving with a few large center single series. Methods: Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. Results: There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6–11.5) vs 8 (5–11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997–2008 and 2008–2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12–0.57; P < 0.001). Conclusions: Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.
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