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An increasing trend of incidence in hepatocellular carcinoma (HCC) has been recorded in most developed countries. HCC ranks among the ten most common cancers worldwide. The health costs and burden to the economy implicated by HCC are huge. In recent years, the surveillance programs and screening for the disease, in addition to increasing awareness, led to the detection of smaller precursor lesions of HCC in the liver. The rise of molecular-targeted therapies and the publication of various conflicting guidelines on the management of the disease demand a review of evidence into the curative therapies and medical management of HCC. The primary objective was to identify the survival benefit of the primary medical modalities in HCC, as more trials were uncovered between 2005 and 2010. The secondary objective was to conduct a meta-analysis. Selection criteria were implemented to select randomized controlled trials (RCTs), to include in this study. After selection, all the articles were ranked according to their strength. The MEDLINE, CANCERLIT, Embase databases, and the Cochrane Library were reviewed using the national library of health website. The time limit used for searching for RCTs was between January 2005 and December 2010. Overall survival and the cumulative probability of no recurrence were the primary endpoints considered in the studies to be assessed. These endpoints were measured over one, two, or three years, depending on the size of the study and the length of follow-up. The software package comprehensive meta-analysis ver 2.0.exe (Biostat, USA) was used to comply with the results, to conduct the meta-analysis, and help with analyzing the data. The original general search yielded 193 RCTs between 2005 and 2010. Only 32 studies met the inclusion criteria. However, after the ranking of the studies according to strength, only 17 studies were eventually selected. The 17 studies were subsequently classified according to the following; surgical resection (n = 2); percutaneous treatments (n = 5); chemoembolization (n = 1); systemic treatments (n = 8); and other treatments (n = 1). Randomized studies comparing the percutaneous ethanol injection (PEI) to the surgical resection were inconclusive. However, percutaneous treatments showed results similar to surgical resection in terms of overall survival. The meta-analysis comparing PEI to radiofrequency ablation (RFA) showed RFA to be superior to PEI in terms of overall survival at three years (odds ratio 1.698; 95% CI 1.206 - 2.391; P = 0.002). When adverse events were considered there was no statistically significant difference between the RFA and PEI groups (odds ratio 1.199; 95% CI 0.571- 2.521; P = 0.632). RFA should be the first-line treatment in patients with a single small HCC tumor ≤ 3 cm. Careful patient selection is crucial prior to transarterial chemoembolization (TACE), as the procedure may be associated with an increased risk of liver failure. Tamoxifen has no role to play in the treatment of HCC. Sorafenib should be the first-line treatment in patients with advanced and inoperable HCC. The role of Sorafenib in the management of early stage HCC remains to be determined.

Introduction C-reactive protein (CRP) has been reported as a predictor of the severity of acute pancreatitis (AP). However, there is conflicting evidence in the literature. The proposed cut-off values and intervals for best prediction include an absolute value of 150 at 48 hours; an absolute value of 190 at 48 hours; and the interval change in CRP of 90 at 48 hours. The current study assesses the value of CRP at different intervals and cut-offs in predicting complicated acute pancreatitis (CAP) and compares its performance against other available predictors like neutrophil to lymphocyte ratio (NLR); Glasgow scoring system and modified CT severity index (MCTSI).  Methods Analysis of prospectively maintained data for index episodes of acute pancreatitis managed in 225 patients over a period of five years (2014-2018) was done. CAP was defined by using revised Atlanta classification and included all the AP patients with local and or systemic complications. It was used as a gold standard. Diagnostic and predictive performance of different biochemical markers and multifactorial scoring systems were determined by analyzing receiving operating curves (ROCs), the area under the curve (AUC), sensitivity, specificity, and predictive values (positive and negative).  Results Out of 225 patients, 122 were female while 103 patients were male. CAP developed in 47 patients (20.9%) while 178 (79.1%) patients had mild AP. Overall, in-hospital mortality rate was 1.8% (n=4). ROC analysis demonstrated that CRP at admission had low discriminatory value (AUC= 0.54, p-value=0.74). CRP at 48 hours had AUC of 0.70 (p-value=0.007). At a cut-off of 150, the positive predictive value (PPV) of 150 was 30 %. The PPV of CRP at 48 hours at a cut-off of 190 was 28%. Interval change in CRP at 48 hours greater than 90 had a PPV of 26 %. Further comparison of CRP with other scoring systems like Glasgow scoring system (AUC= 0.65), NL ratio (AUC=0.54), and MCTSI was performed. Among the single predictors, although, NL ratio showed good sensitivity at a cut-off value of 4.7 (87.23%), however, its discriminatory power was negligible (AUC=0.542, p-value=0.513). The overall best performance was achieved by the MCTSI scoring system at a cut-off of 3 (AUC=0.90, sensitivity=83.33 %, specificity=100%, diagnostic accuracy=94.49%).  Conclusion CRP measured at admission or at 48 hours has a very limited role in the prediction of CAP. Along with other scoring systems, its negative predictive value should be used to predict cases with mild AP which can help in clinical decision making for early discharge or management of such patients on ambulatory care basis. MCTSI scoring system can be used in cases with high suspicion of CAP.

. The role of liver transplantation in malignancy has been discussed, but controversially, over the past two decades. This is particularly true for hepatic metastases from neuroendocrine tumors, which have a wide variety of primary tumor localizations, morphologic types, functional activities, and clinical presentations. Despite generally slow tumor progression, the prognosis is often unpredictable. Total hepatectomy and liver replacement has been offered primarily to patients with nonresectable metastases and symptomatic disease. The results from retrospective single and multicentric analyses show that most liver recipients experience significant palliation despite tumor recurrence, and in some patients long‐term cure can be achieved. The existing data emphasize the importance of proper selection and timing for this approach.

This unique volume presents the cutting edge of haemostasis in surgery and includes the advances in the science pertaining to related important medical and surgical problems. It is the only book that includes all the surgical subspecialties focusing specifically on the problems of haemostasis in each field. State-of-the-art laboratory and clinical reviews are included and modern devices used in the different specialties are also covered. The contributors are well-known authorities in their special fields and haematological area.

IntroductionCONTACT is a national multidisciplinary study assessing the impact of the COVID-19 pandemic upon diagnostic and treatment pathways among patients with pancreatic ductal adenocarcinoma (PDAC).MethodsThe treatment of consecutive patients with newly diagnosed PDAC from a pre-COVID-19 pandemic cohort (07/01/2019-03/03/2019) were compared to a cohort diagnosed during the first wave of the UK pandemic (‘COVID’ cohort, 16/03/2020-10/05/2020), with 12-month follow-up.ResultsAmong 984 patients (pre-COVID: n = 483, COVID: n = 501), the COVID cohort was less likely to receive staging investigations other than CT scanning (29.5% vs. 37.2%, p = 0.010). Among patients treated with curative intent, there was a reduction in the proportion of patients recommended surgery (54.5% vs. 76.6%, p = 0.001) and increase in the proportion recommended upfront chemotherapy (45.5% vs. 23.4%, p = 0.002). Among patients on a non-curative pathway, fewer patients were recommended (47.4% vs. 57.3%, p = 0.004) or received palliative anti-cancer therapy (20.5% vs. 26.5%, p = 0.045). Ultimately, fewer patients in the COVID cohort underwent surgical resection (6.4% vs. 9.3%, p = 0.036), whilst more patients received no anti-cancer treatment (69.3% vs. 59.2% p = 0.009). Despite these differences, there was no difference in median overall survival between the COVID and pre-COVID cohorts, (3.5 (IQR 2.8–4.1) vs. 4.4 (IQR 3.6–5.2) months, p = 0.093).ConclusionPathways for patients with PDAC were significantly disrupted during the first wave of the COVID-19 pandemic, with fewer patients receiving standard treatments. However, no significant impact on survival was discerned.

The book is designed to highlight recent updates in living related transplants, with chapters by leaders in the different types of transplantation. There are very few texts that tackle living donor liver, lung, pancreas and intestinal transplantation as well as the connected ethical issues. With some color photographs illustrating procedures, this concise book will be a valuable resource for students or professionals interested in developing a global view of the ethics and practice of transplantation.

IntroductionHuman error contributes to the majority of adverse events in the operating theatre environment. Many processes exist to limit the incidence of such adverse events. However, the role of technology and device advancement has been limited in this respect.MethodsA dual-controlled accessory electrical diathermy footswitch (abortive diathermy footswitch device or ADF) concept was developed in an attempt to improve patient safety in theatre. The activation of the ADF allows a senior surgeon to control the activation of diathermy devices by a junior surgeon by deactivating diathermy devices when the ADF footswitch is operated.ResultsThe ADF device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was clinically tested during two separate theatre sessions involving five elective laparoscopic cholecystectomies.ConclusionsWe demonstrated the feasibility and functionality of the ADF device and propose a role in surgical training through potentially limiting surgical errors associated with the use of electrical diathermy during training and expanding accessible surgical experience.

Introduction: An increasing trend of incidence in hepatocellular carcinoma (HCC) has been recorded in most developed countries. HCC ranks among the ten most common cancers worldwide. The health costs and burden to the economy implicated by HCC are huge. In recent years, the surveillance programs and screening for the disease, in addition to increasing awareness, led to the detection of smaller precursor lesions of HCC in the liver. The rise of molecular-targeted therapies and the publication of various conflicting guidelines on the management of the disease demand a review of evidence into the curative therapies and medical management of HCC. Aims: The primary objective was to identify the survival benefit of the primary medical modalities in HCC, as more trials were uncovered between 2005 and 2010. The secondary objective was to conduct a meta-analysis. Selection criteria were implemented to select randomized controlled trials (RCTs), to include in this study. After selection, all the articles were ranked according to their strength. Materials and Methods: The MEDLINE, CANCERLIT, Embase databases, and the Cochrane Library were reviewed using the national library of health website. The time limit used for searching for RCTs was between January 2005 and December 2010. Overall survival and the cumulative probability of no recurrence were the primary endpoints considered in the studies to be assessed. These endpoints were measured over one, two, or three years, depending on the size of the study and the length of follow-up. The software package comprehensive meta-analysis ver 2.0.exe (Biostat, USA) was used to comply with the results, to conduct the meta-analysis, and help with analyzing the data. Results: The original general search yielded 193 RCTs between 2005 and 2010. Only 32 studies met the inclusion criteria. However, after the ranking of the studies according to strength, only 17 studies were eventually selected. The 17 studies were subsequently classified according to the following; surgical resection (n = 2); percutaneous treatments (n = 5); chemoembolization (n = 1); systemic treatments (n = 8); and other treatments (n = 1). Randomized studies comparing the percutaneous ethanol injection (PEI) to the surgical resection were inconclusive. However, percutaneous treatments showed results similar to surgical resection in terms of overall survival. The meta-analysis comparing PEI to radiofrequency ablation (RFA) showed RFA to be superior to PEI in terms of overall survival at three years (odds ratio 1.698; 95% CI 1.206 - 2.391; P = 0.002). When adverse events were considered there was no statistically significant difference between the RFA and PEI groups (odds ratio 1.199; 95% CI 0.571- 2.521; P = 0.632). Conclusion: RFA should be the first-line treatment in patients with a single small HCC tumor ≤ 3 cm. Careful patient selection is crucial prior to transarterial chemoembolization (TACE), as the procedure may be associated with an increased risk of liver failure. Tamoxifen has no role to play in the treatment of HCC. Sorafenib should be the first-line treatment in patients with advanced and inoperable HCC. The role of Sorafenib in the management of early stage HCC remains to be determined.