Colorectal liver metastases: Current management and future perspectives

The liver is the commonest site of metastatic disease for patients with colorectal cancer,with at least 25%developing colorectal liver metastases(CRLM)during the course of their illness.The management of CRLM has evolved into a complex field requiring input from experienced members of a multi-disciplinary team involving radiology(cross sectional,nuclear medicine and interventional),Oncology,Liver surgery,Colorectal surgery,and Histopathology.Patient management is based on assessment of sophisticated clinical,radiological and biomarker information.Despite incomplete evidence in this very heterogeneous patient group,maximising resection of CRLM using all available techniques remains a key objective and provides the best chance of long-term survival and cure.To this end,liver resection is maximised by the use of downsizing chemotherapy,optimisation of liver remnant by portal vein embolization,associating liver partition and portal vein ligation for staged hepatectomy,and combining resection with ablation,in the context of improvements in the functional assessment of the future remnant liver.Liver resection may safely be carried out laparoscopically or open,and synchronously with,or before,colorectal surgery in selected patients.For unresectable patients,treatment options including systemic chemotherapy,targeted biological agents,intraarterial infusion or bead delivered chemotherapy,tumour ablation,stereotactic radiotherapy,and selective internal radiotherapy contribute to improve survival and may convert initially unresectable patients to operability.Currently evolving areas include biomarker characterisation of tumours,the development of novel systemic agents targeting specific oncogenic pathways,and the potential reemergence of radical surgical options such as liver transplantation.

Is there a role for serum endothelin in predicting the severity of acute pancreatitis?

BACKGROUND: Acute pancreatitis remains a common presentation to acute surgical units and carries significant morbidity and mortality. The progression of the disease to necrotizing pancreatitis and multi-organ dysfunction syndrome (MODS) is associated with a very poor clinical outcome, and persistendy high mortality. Increases in serum endothelin (ET) have been seen in animal models of acute pancreatitis and this study aims to investigate whether there is a change in serum ET-1 in patients with acute pancreatitis and whether any such change is linked to disease severity. METHODS: All patients admitted with acute pancreatitis were prospectively recruited from die emergency admissions at the Norfolk and Norwich University Hospital. Serum ET levels were determined on admission, at 24 hours and 5 days post admission. Healthy adult controls were recruited from dermatology outpatients. RESULTS: A total of 21 patients joined the trial after giving informed consent. There were 3 men and 18 women with a median age of 65 years (range 26-87 years). Serum ET levels were significantly higher in acute pancreatitis patients than in normal controls (P <0. 05). An association was seen between persistendy raised serum ET levels and progression to MODS. CONCLUSIONS: The study does demonstrate a correlation between the circulating levels of ET and acute pancreatitis in humans, although it does not elicit its involvement in the pathogenesis of the disease. The observation that a persistendy high level of circulating ET-1 is associated with progression to MODS may indicate a role for ET in the monitoring of acute pancreatitis patients for recovery or progression to MODS.