Results: The analysis included 46 patients in the ERP group and 45 in the standard care group. Median MFD time was reduced in the ERP group (3 days versus 6 days with standard care; P < 0·001), as was LOS (4 days versus 7 days; P < 0·001). The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0·020), but not surgical complications (15 versus 11 per cent; P = 0·612), readmissions (4 versus 0 per cent; P = 0·153) or mortality (both 2 per cent; P = 0·987). QoL over 28 days was significantly better in the ERP group (P = 0·002). There was no difference in patient satisfaction. Conclusion:ERPs for open liver resection surgery are safe and effective. Patients treated in the ERP recovered faster, were discharged sooner, and had fewer medical-related complications and improved QoL. Registration number: ISRCTN03274575 (http://www.controlled-trials.com).

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Ann RC oll Surg Engl 2009; 91:4 83-488 483Colorectal carcinoma is common in the Western world. 1,2 Approximately 50% of patients diagnosed with the disease develop liver metastases. 3,4 Currently,f or patients with colorectal liver metastases, liver resection offers the only potential chance for cure. However,t he proportion of patients with colorectal liver metastasese ligible for liver resection remains low (20-30%), 5,6 although there has been asteady increase over the past 10-15 years, [1][2][3][4] largely due to improvements in pre-operative assessment and selection and the use of neo-adjuvant chemotherapy.Studies have reported factors that influence early and long-term survival. 7-10Over the past 10 years in our unit, it was felt that diaphragm invasion and subsequent diaphragm excision at the time of liver resection predicted an adverse outcome. To the authors' knowledge there have not been any reports in the literature focusing on diaphragm excision with liver resection for colorectal liver metastases.Therefore, this study was undertaken to compare those patients who had liver resection and diaphragm excision with those who had liver resection alone, for colorectal liver metastases. Patients and MethodsAtotal of 285 consecutive completed liver resections for colorectal liver metastases in asingle unit over a10-year period (September 1996 to November 2006) were studied. Of these, 27 patients underwent liver resection and diaphragm excision simultaneously and 258 underwent liver resection At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However,t here are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients.

Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.