Extracorporeal shock wave lithotripsy for pancreatic duct stones in patients with chronic pancreatitis: Are we underutilizing a new technology?

SummaryThe progressive inflammatory nature of chronic pancreatitis and its sparse therapeutic toolbox remain obstacles in offering patients durable solutions for their symptoms. Obstruction of the main pancreatic duct by either strictures or stones represents a scenario worthy of therapeutic focus, as nearly all patients with pancreatitis eventually have intraductal stones. A more recent option for removal of main duct stones is extracorporeal shock wave lithotripsy (ESWL). In an effort to explore the role of ESWL in a Canadian setting, we evaluated our initial experience over an 8-year period (2011-2019).

Is the Pringle manoeuvre becoming a lost art? Contemporary use for both severe liver trauma with ongoing hemorrhage and elective partial hepatectomy

SummaryThe Pringle manoeuvre (vascular inflow occlusion) has been a mainstay technique in trauma surgery and hepato-pancreato-biliary surgery since it was first described in the early 1900s. We sought to determine how frequently the manoeuvre is used today for both elective and emergent cases in these disciplines. To reflect on its evolution, we evaluated the Pringle manoeuvre over a recent 10-year period (2010-2020). We found it is used less frequently owing to more frequent nonoperative management and more advanced elective hepatic resection techniques. Continuing educational collaboration is critical to ensure continued insight into the impact of hepatic vascular inflow occlusion among trainees who observe this procedure less frequently.

Preoperative Single-dose Methylprednisolone Prevents Surgical Site Infections After Major Liver Resection: A Randomized Controlled Trial

OBJECTIVE

The primary aim of this study was to evaluate the efficacy of a single preoperative dose of methylprednisolone for preventing postoperative complications after major liver resections.

SUMMARY BACKGROUND DATA

Hepatic resections are associated with a significant acute systemic inflammatory response. This effect subsequently correlates with postoperative morbidity, mortality, and length of recovery. Multiple small trials have proposed that the administration of glucocorticoids may modulate this effect.

METHODS

This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients undergoing elective major hepatic resection (≥3 segments) at a quaternary care institution were included (2013-2019). Patients were randomly assigned to receive a single preoperative 500 mg dose of methylprednisolone versus placebo. The main outcome measure was postoperative complications after liver resection, within 90 days of the index operation. Standard statistical methodology was employed (P < 0.05 = significant).

RESULTS

A total of 151 patients who underwent a major hepatic resection were randomized (mean age = 62.8 years; 57% male; body-mass-index = 27.9). No significant differences were identified between the intervention and control groups (age, sex, body-mass-index, preoperative comorbidities, hepatic function, ASA class, portal vein embolization rate) (P > 0.05). Underlying hepatic diagnoses included colorectal liver metastases (69%), hepatocellular carcinoma (18%), noncolorectal liver metastases (7%), and intrahepatic cholangiocarcinoma (6%). There was a significant reduction in the overall incidence of postoperative complications in the methylprednisolone group (31.2% vs 47.3%; P = 0.042). Patients in the glucocorticoid group also displayed less frequent organ space surgical site infections (6.5% vs 17.6%; P = 0.036), as well as a shorter length of hospital stay (8.9 vs 12.5 days; P = 0.015). Postoperative serum bilirubin and prothrombin timeinternational normalized ratio (PT-INR) levels were also lower in the steroid group (P = 0.03 and 0.04, respectively). Multivariate analysis did not identify any additional significant modifying factor relationships (estimated blood loss, duration of surgery, hepatic vascular occlusion (rate or duration), portal vein embolization, drain use, etc) (P > 0.05).

CONCLUSIONS

A single preoperative dose of methylprednisolone significantly reduces the length of hospital stay, postoperative serum bilirubin, and PT-INR, as well as infectious and overall complications following major hepatectomy.

The art and craft of biliary T-tube Use

INTRODUCTION

Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management.

METHODS

Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage.

RESULTS

Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting.

CONCLUSIONS

Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use.

LEVEL OF EVIDENCE

Expert opinion, level V.

Acute kidney injury following resection of hepatocellular carcinoma: prognostic value of the acute kidney injury network criteria

Background

Acute kidney injury (AKI) is associated with increased morbidity and mortality after liver resection. Patients with hepatocellular carcinoma (HCC) have a higher risk of AKI owing to the underlying association between hepatic and renal dysfunction. Use of the Acute Kidney Injury Network (AKIN) diagnostic criteria is recommended for patients with cirrhosis, but remains poorly studied following liver resection. We compared the prognostic value of the AKIN creatinine and urine output criteria in terms of postoperative outcomes following liver resection for HCC.

Methods

All patients who underwent a liver resection for HCC from January 2010 to June 2016 were included. We used AKIN urine output and creatinine criteria to assess for AKI within 48 hours of surgery.

Results

Eighty liver resections were performed during the study period. Cirrhosis was confirmed in 80%. Median hospital stay was 9 (interquartile range 7–12) days, and 30-day mortality was 2.5%. The incidence of AKI was higher based on the urine output than on the creatinine criterion (53.8% v. 20%), and was associated with prolonged hospitalization and 30-day postoperative mortality when defined by serum creatinine (hospital stay: 11.2 v. 20.1 d, p = 0.01; mortality: 12.5% v. 0%, p < 0.01), but not urine output (hospital stay: 15.6 v. 10 d, p = 0.05; mortality: 2.3% v. 2.7%, p > 0.99).

Conclusion

The urine output criterion resulted in an overestimation of AKI and compromised the prognostic value of AKIN criteria. Revision may be required to account for the exacerbated physiologic postoperative reduction in urine output in patients with HCC.

Host phenotype is associated with reduced survival independent of tumour biology in patients with colorectal liver metastases

BACKGROUND

Most prognostic scoring systems for colorectal liver metastases (CRLMs) account for factors related to tumour biology. Little is known about the effects of the host phenotype to the tumour. Our objective was to delineate the relationship of systemic inflammation and body composition features [i.e. low skeletal muscle mass (sarcopenia) and low visceral adipose tissue (VAT)], two well-described host phenotypes in cancer.

METHODS

Clinical data and pre-operative blood samples were collected from 99 patients who underwent resection of CRLM. Pre-operative computed tomography scans were available for 97 patients; body composition was analysed at the L3 level, stratified for sex and age. Clinicopathological variables, serum C-reactive protein (CRP), and various body composition variables were evaluated. Overall survival was evaluated as a function of these same variables in multivariate Cox regression analysis.

RESULTS

Skeletal muscle was significantly correlated with VAT (r = 0.46, P < 0.001). Of patients with sarcopenia, 35 (65%) also had low VAT. C-reactive protein was elevated (≥5 mg/mL) in 42 patients (43.3%). Elevated CRP was more common in patients with sarcopenia (73.8% vs. 51.1%, P = 0.029). The most significant prognostic factors were the coincidence of elevated CRP and adverse body composition features (sarcopenia and/or low VAT; hazard ratio 4.3, 95% confidence interval 1.5-13.0, P = 0.008), as well as Fong clinical prognostic score (hazard ratio 2.9, 95% confidence interval 1.5-5.5, P = 0.002).

CONCLUSIONS

Body composition in patients with CRLM is not directly linked to the presence of systemic inflammation. However, when systemic inflammation coincides with sarcopenia and/or low VAT, prognosis is adversely affected, independent of the Fong clinical prognostic score.

Effect of proximity to specialty care on outcomes for biliary cancers: a population-based retrospective cohort study

BACKGROUND

The management of biliary cancers is complex and requires a multidisciplinary approach. Because it is unknown how access to specialty care affects resource use and survival in patients with biliary cancer, we conducted a population-based study to understand the needs of these patients and the relation of geography to care delivery and clinical outcomes for biliary cancer in Alberta.

METHODS

All patients with biliary cancer diagnosed in Alberta from Sept. 1, 2001, to Dec. 31, 2015 were included in this population-based retrospective cohort study. Data were extracted from administrative databases and the 2011 Canadian census. Driving time and types of medical services were tracked throughout the patients' clinical course. We categorized proximity to specialty care according to driving time to the nearest specialist. The primary outcome was overall survival. We conducted Cox proportional hazard regression to evaluate the effects of driving time on overall survival and multivariate logistic regression to evaluate the effect of driving time on treatment types and stage at diagnosis.

RESULTS

We identified 1610 patients with biliary cancer; they accounted for 117 381 medical encounters. Patients living 120 minutes or more from the nearest hepatobiliary surgeon and from the nearest cancer centre had significantly decreased survival (hazard ratio [and 95% confidence interval (CI)] 1.27 [1.17-1.37]) and 1.27 [1.14-1.41], respectively). Location of residence was not associated with advanced stage or probability of undergoing surgery or a biliary drainage procedure. Patients who lived 120 minutes or more from a cancer centre were less likely than those who lived less than 120 minutes away to receive chemotherapy (odds ratio 0.51, 95% CI 0.29-0.88). Subgroup analysis showed that the effect of travel time was especially pronounced among those who received only best supportive care and those who had biliary drains.

INTERPRETATION

Geography and accessibility to specialty care affected survival in patients with biliary cancer. Further study is required to understand how patients with biliary drains and those receiving best supportive care are affected by proximity to specialty care. This will aid in the identification of strategies to provide improved care for this subgroup who are particularly affected by geography.

Sarcopenia and myosteatosis are accompanied by distinct biological profiles in patients with pancreatic and periampullary adenocarcinomas

Introduction

Pancreatic and periampullary adenocarcinomas are associated with abnormal body composition visible on CT scans, including low muscle mass (sarcopenia) and low muscle radiodensity due to fat infiltration in muscle (myosteatosis). The biological and clinical correlates to these features are poorly understood.

Methods

Clinical characteristics and outcomes were studied in 123 patients who underwent pancreaticoduodenectomy for pancreatic or non-pancreatic periampullary adenocarcinoma and who had available preoperative CT scans. In a subgroup of patients with pancreatic cancer (n = 29), rectus abdominus muscle mRNA expression was determined by cDNA microarray and in another subgroup (n = 29) ¹H-NMR spectroscopy and gas chromatography-mass spectrometry were used to characterize the serum metabolome.

Results

Muscle mass and radiodensity were not significantly correlated. Distinct groups were identified: sarcopenia (40.7%), myosteatosis (25.2%), both (11.4%). Fat distribution differed in these groups; sarcopenia associated with lower subcutaneous adipose tissue (P<0.0001) and myosteatosis associated with greater visceral adipose tissue (P<0.0001). Sarcopenia, myosteatosis and their combined presence associated with shorter survival, Log Rank P = 0.005, P = 0.06, and P = 0.002, respectively. In muscle, transcriptomic analysis suggested increased inflammation and decreased growth in sarcopenia and disrupted oxidative phosphorylation and lipid accumulation in myosteatosis. In the circulating metabolome, metabolites consistent with muscle catabolism associated with sarcopenia. Metabolites consistent with disordered carbohydrate metabolism were identified in both sarcopenia and myosteatosis.

Discussion

Muscle phenotypes differ clinically and biologically. Because these muscle phenotypes are linked to poor survival, it will be imperative to delineate their pathophysiologic mechanisms, including whether they are driven by variable tumor biology or host response.

Distinguishing Benign from Malignant Pancreatic and Periampullary Lesions Using Combined Use of ¹H-NMR Spectroscopy and Gas Chromatography-Mass Spectrometry

Previous work demonstrated that serum metabolomics can distinguish pancreatic cancer from benign disease. However, in the clinic, non-pancreatic periampullary cancers are difficult to distinguish from pancreatic cancer. Therefore, to test the clinical utility of this technology, we determined whether any pancreatic and periampullary adenocarcinoma could be distinguished from benign masses and biliary strictures. Sera from 157 patients with malignant and benign pancreatic and periampullary lesions were analyzed using proton nuclear magnetic resonance (¹H-NMR) spectroscopy and gas chromatography–mass spectrometry (GC-MS). Multivariate projection modeling using SIMCA-P+ software in training datasets (n = 80) was used to generate the best models to differentiate disease states. Models were validated in test datasets (n = 77). The final ¹H-NMR spectroscopy and GC-MS metabolomic profiles consisted of 14 and 18 compounds, with AUROC values of 0.74 (SE 0.06) and 0.62 (SE 0.08), respectively. The combination of ¹H-NMR spectroscopy and GC-MS metabolites did not substantially improve this performance (AUROC 0.66, SE 0.08). In patients with adenocarcinoma, glutamate levels were consistently higher, while glutamine and alanine levels were consistently lower. Pancreatic and periampullary adenocarcinomas can be distinguished from benign lesions. To further enhance the discriminatory power of metabolomics in this setting, it will be important to identify the metabolomic changes that characterize each of the subclasses of this heterogeneous group of cancers.

Effect of N-acetylcysteine on liver recovery after resection: A randomized clinical trial

BACKGROUND AND OBJECTIVES

Liver failure following hepatic resection is a multifactorial complication. In experimental studies, infusion of N-acetylcysteine (NAC) can minimize hepatic parenchymal injury.

METHODS

Patients undergoing liver resection were randomized to postoperative care with or without NAC. No blinding was performed. Overall complication rate was the primary outcome; liver failure, length of stay, and mortality were secondary outcomes. Due to safety concerns, a premature multivariate analysis was performed and included within the model randomization to NAC, preoperative ASA, extent of resection, and intraoperative vascular occlusion as factors.

RESULTS

Two hundred and six patients were randomized (110 to conventional therapy; 96 to NAC). No significant differences were noted in overall complications (32.7% and 45.7%, P = 0.06) or hepatic failure (3.6% and 5.4%, P = 0.537) between treatment groups. There was significantly more delirium within the NAC group (2.7% and 9.8%, P < 0.05) that caused early trial termination. In multivariate analysis, only randomization to NAC (OR = 2.21, 95%CI = 1.16-4.19) and extensive resections (OR = 2.28, 95%CI = 1.22-4.29) were predictive of postoperative complications.

CONCLUSIONS

Patients randomized to postoperative NAC received no benefit. There was a trend toward a higher rate of overall complications and a significantly higher rate of delirium in the NAC group. J. Surg. Oncol. 2016;114:446-450. © 2016 Wiley Periodicals, Inc.

Preoperative single-dose methylprednisolone versus placebo after major liver resection in adults: protocol for a randomised controlled trial

INTRODUCTION

Although randomised controlled trials have demonstrated that preoperative glucocorticoids may improve postoperative surrogate outcomes among patients undergoing major liver resection, evidence supporting improved patient-important outcomes is lacking. This superiority trial aims to evaluate the effect of administration of a bolus of the glucocorticoid methylprednisolone versus placebo during induction of anaesthesia on postoperative morbidity among adults undergoing elective major liver resection.

METHODS AND ANALYSIS

This will be a randomised, dual-arm, parallel-group, superiority trial. All consecutive adults presenting to a large Canadian tertiary care hospital who consent to undergo major liver resection will be included. Patients aged <18 years and those currently receiving systemic corticosteroid therapy will be excluded. We will randomly allocate participants to a preoperative 500 mg intravenous bolus of methylprednisolone versus placebo. Surgical team members and outcome assessors will be blinded to treatment allocation status. The primary outcome measure will be postoperative complications. Secondary outcome measures will include mortality, the incidence of several specific postoperative complications, and blood levels of select proinflammatory cytokines, acute-phase proteins, and laboratory liver enzymes or function tests on postoperative days 0, 1, 2 and 5. The incidence of postoperative complications and mortality will be compared using Fisher's exact test, while the above laboratory measures will be compared using mixed-effects models with a subject-specific random intercept.

ETHICS AND DISSEMINATION

This trial will evaluate the protective effect of a single preoperative dose of methylprednisolone on the hazard of postoperative complications. A report releasing study results will be submitted for publication in an appropriate journal, approximately 3 months after finishing the data collection.

TRIAL REGISTRATION NUMBER

NCT01997658; Pre-results.

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

BACKGROUND

It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD).

METHODS

A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and χ(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression.

RESULTS

Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003).

CONCLUSION

There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

The diagnostic pathway for solid pancreatic neoplasms: are we applying too many tests?

BACKGROUND

The single best diagnostic and staging test for pancreatic cancer remains a contrast-enhanced computed tomography scan. It is frequently the only imaging test required before surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care.

MATERIALS AND METHODS

A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume Hepato-Pancreato-Biliary (HPB) service over 4 y (2008-2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was used (P < 0.05).

RESULTS

Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasonography and computed tomography for 75 (58%) and 52 (40%), respectively. Patients underwent a mean of 1.3 diagnostic tests after the index study and before consultation with HPB surgery (range: 0-5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests. The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 d, respectively. If four interval tests were conducted, the mean was 69.4 and 122.6 d, respectively. Sixty-two patients (48%) were initially referred to a nonsurgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 d, respectively. This compares to 19.8 and 48.1 d, respectively, in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed before HPB consultation if a nonsurgical referral occurred was 2.1 (versus 0.7 if direct HPB surgeon referral).

CONCLUSIONS

Despite a relatively simple algorithm for the investigation of solid pancreatic lesions, considerable heterogeneity remains in how these patients are evaluated before referral to HPB surgery. As the number of investigations increases after the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Education is required to expedite care and mitigate excess diagnostic tests.

Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial

INTRODUCTION

Among surgical oncology patients, incisional surgical site infection is associated with substantially increased morbidity, mortality and healthcare costs. Moreover, while adults undergoing pancreaticoduodenectomy with preoperative placement of an intrabiliary stent have a high risk of this type of infection, and wound protectors may significantly reduce its risk, no relevant studies of wound protectors yet exist involving this patient population. This study will evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among adults undergoing pancreaticoduodenectomy with preoperatively-placed intrabiliary stents.

METHODS AND ANALYSIS

This study will be a parallel, dual-arm, randomised controlled trial that will utilise a more explanatory than pragmatic attitude. All adults (≥18 years) undergoing a pancreaticoduodenectomy at the Foothills Medical Centre in Calgary, Alberta, Canada with preoperative placement of an intrabiliary stent will be considered eligible. Exclusion criteria will include patient age <18 years and those receiving long-term glucocorticoids. The trial will employ block randomisation to allocate patients to a commercial dual-ring wound protector (the Alexis Wound Protector) or no wound protector and the current standard of care. The main outcome measure will be the rate of surgical site infection as defined by the Centers for Disease Control and Prevention criteria within 30 days of the index operation date as determined by a research assistant blinded to treatment allocation. Outcomes will be analysed by a statistician blinded to allocation status by calculating risk ratios and 95% CIs and compared using Fisher's exact test.

ETHICS AND DISSEMINATION

This will be the first randomised trial to evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among patients undergoing pancreaticoduodenectomy. Results of this study are expected to be available in 2016/2017 and will be disseminated using an integrated and end-of-grant knowledge translation strategy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT01836237.

Identification of prognostic inflammatory factors in colorectal liver metastases

Background

The modified Glasgow Prognostic Score (mGPS) has been reported to be an important prognostic indicator in a number of tumor types, including colorectal cancer (CRC). The features of the inflammatory state thought to accompany elevated C-reactive protein (CRP), a key feature of mGPS, were characterized in patients with colorectal liver metastases. Additional inflammatory mediators that contribute to prognosis were explored.

Methods

In sera from 69 patients with colorectal liver metastases, a panel of 42 inflammatory mediators were quantified as a function of CRP levels, and as a function of disease-free survival. Multivariate statistical methods were used to determine association of each mediator with elevated CRP and truncated disease-free survival.

Results

Elevated CRP was confirmed to be a strong predictor of survival (HR 4.00, p = 0.001) and recurrence (HR 3.30, p = 0.002). The inflammatory state associated with elevated CRP was comprised of raised IL-1β, IL-6, IL-12 and IL-15. In addition, elevated IL-8 and PDGF-AB/BB and decreased eotaxin and IP-10 were associated with worse disease-free and overall survival.

Conclusions

Elevated CRP is associated with a proinflammatory state. The inflammatory state is an important prognostic indicator in CRC liver metastases. The individual contributions of tumor biology and the host to this inflammatory response will require further investigation.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-542) contains supplementary material, which is available to authorized users.

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey

BACKGROUND

Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors.

METHODS

We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care.

RESULTS

A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05).

CONCLUSION

Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

The impact of an acute care surgery clinical care pathway for suspected appendicitis on the use of CT in the emergency department

BACKGROUND

The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED).

METHODS

All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: pre- and postimplementation of the disease-specific pathway and at 12-month follow-up.

RESULTS

Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month followup (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040).

CONCLUSION

A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention.

Severe street and mountain bicycling injuries in adults: a comparison of the incidence, risk factors and injury patterns over 14 years

BACKGROUND

Street and mountain bicycling are popular recreational activities and prevalent modes of transportation with the potential for severe injury. The purpose of this investigation was to compare the incidence, risk factors and injury patterns among adults with severe street versus mountain bicycling injuries.

METHODS

We conducted a retrospective cohort study using the Southern Alberta Trauma Database of all adults who were severely injured (injury severity score [ISS] ≥ 12) while street or mountain bicycling between Apr. 1, 1995, and Mar. 31, 2009.

RESULTS

Among 11 772 severely injured patients, 258 (2.2%) were injured (mean ISS 17, hospital stay 6 d, mortality 7%) while street (n = 209) or mountain bicycling (n = 49). Street cyclists were often injured after being struck by a motor vehicle, whereas mountain bikers were frequently injured after faulty jump attempts, bike tricks and falls (cliffs, roadsides, embankments). Mountain cyclists were admitted more often on weekends than weekdays (61.2% v. 45.0%, p = 0.040). Injury patterns were similar for both cohorts (all p > 0.05), with trauma to the head (67.4%), extremities (38.4%), chest (34.1%), face (26.0%) and abdomen (10.1%) being common. Spinal injuries, however, were more frequent among mountain cyclists (65.3% v. 41.1%, p = 0.003). Surgical intervention was required in 33.3% of patients (9.7% open reduction internal fixation, 7.8% spinal fixation, 7.0% craniotomy, 5.8% facial repair and 2.7% laparotomy).

CONCLUSION

With the exception of spine injuries, severely injured cyclists display similar patterns of injury and comparable outcomes, regardless of style (street v. mountain). Helmets and thoracic protection should be advocated for injury prevention.

The effect of wait times on oncological outcomes from periampullary adenocarcinomas

BACKGROUND

Overall few patients presenting with periampullary adenocarcinomas have resectable lesions. We postulated that rapid diagnosis and treatment would enhance the likelihood of successful resection, improving survival.

METHODS

A retrospective analysis of patients undergoing surgery for resection of a pancreatic or periampullary lesion was conducted. Resection rate, disease stage and survival were evaluated as a function of wait times.

RESULTS

Pancreatic resections were booked in 355 patients. Of 193 patients with periampullary adenocarcinomas, 119 patients (61.7%) had resectable disease. There was no difference in median time from initial physician consultation to surgery in patients with resectable and unresectable disease (61 days vs. 64 days, respectively). The likelihood of successful resection was virtually identical in patients with wait times ≤ 30 and > 30 days (from surgical consultation to procedure). There was a trend toward a higher T-stage in patients who waited >30 days for surgery (P = 0.055). However, there was no difference in survival as a function of wait time.

CONCLUSIONS

This series does not demonstrate an advantage for rapid diagnosis and surgery, in terms of resection rate and survival. However, further study is required in a larger cohort of patients, to confirm these findings.

Serum metabolomic profile as a means to distinguish stage of colorectal cancer

BACKGROUND

Presently, colorectal cancer (CRC) is staged preoperatively by radiographic tests, and postoperatively by pathological evaluation of available surgical specimens. However, present staging methods do not accurately identify occult metastases. This has a direct effect on clinical management. Early identification of metastases isolated to the liver may enable surgical resection, whereas more disseminated disease may be best treated with palliative chemotherapy.

METHODS

Sera from 103 patients with colorectal adenocarcinoma treated at the same tertiary cancer center were analyzed by proton nuclear magnetic resonance (1H NMR) spectroscopy and gas chromatography-mass spectroscopy (GC-MS). Metabolic profiling was done using both supervised pattern recognition and orthogonal partial least squares-discriminant analysis (O-PLS-DA) of the most significant metabolites, which enables comparison of the whole sample spectrum between groups. The metabolomic profiles generated from each platform were compared between the following groups: locoregional CRC (N = 42); liver-only metastases (N = 45); and extrahepatic metastases (N = 25).

RESULTS

The serum metabolomic profile associated with locoregional CRC was distinct from that associated with liver-only metastases, based on 1H NMR spectroscopy (P = 5.10 × 10-7) and GC-MS (P = 1.79 × 10-7). Similarly, the serum metabolomic profile differed significantly between patients with liver-only metastases and with extrahepatic metastases. The change in metabolomic profile was most markedly demonstrated on GC-MS (P = 4.75 × 10-5).

CONCLUSIONS

In CRC, the serum metabolomic profile changes markedly with metastasis, and site of disease also appears to affect the pattern of circulating metabolites. This novel observation may have clinical utility in enhancing staging accuracy and selecting patients for surgical or medical management. Additional studies are required to determine the sensitivity of this approach to detect subtle or occult metastatic disease.

Feasibility of identifying pancreatic cancer based on serum metabolomics

BACKGROUND

We postulated that the abundance of various metabolites in blood would facilitate the diagnosis of pancreatic and biliary lesions, which could potentially prevent unnecessary surgery.

METHODS

Serum samples from patients with benign hepatobiliary disease (n = 43) and from patients with pancreatic cancer (n = 56) were examined by ¹H NMR spectroscopy to quantify 58 unique metabolites. Data were analyzed by "targeted profiling" followed by supervised pattern recognition and orthogonal partial least-squares discriminant analysis (O-PLS-DA) of the most significant metabolites, which enables comparison of the whole sample spectrum between groups.

RESULTS

The metabolomic profile of patients with pancreatic cancer was significantly different from that of patients with benign disease (AUROC, area under the ROC curve, = 0.8372). Overt diabetes mellitus (DM) was identified as a possible confounding factor in the pancreatic cancer group. Thus, diabetics were excluded from further analysis. In this more homogeneous pancreatic cancer group, compared with benign cases, serum concentrations of glutamate and glucose were most elevated on multivariate analysis. In benign cases, creatine and glutamine were most abundant. To examine the usefulness of this test, a comparison was made to age- and gender-matched controls with benign lesions that mimic cancer, controlling also for presence of jaundice and diabetes (n = 14 per group). The metabolic profile in patients with pancreatic cancer remained distinguishable from patients with benign pancreatic lesions (AUROC = 0.8308).

CONCLUSIONS

The serum metabolomic profile may be useful for distinguishing benign from malignant pancreatic lesions.

IMPACT

Further studies will be required to study the effects of jaundice and diabetes. A more comprehensive metabolomic profile will be evaluated using mass spectrometry.

Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy

BACKGROUND

Minimization of blood loss during pancreatoduodenectomy requires careful surgical technique and specific preventative measures. Therefore, red blood cell (RBC) transfusions and operative time are potential surgical quality indicators. The aim of the present study was to compare peri-operative RBC transfusion and operative time with 30-day morbidity/mortality after pancreatoduodenectomy.

METHODS

All pancreatoduodenectomies (2005 to 2008) were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). RBC transfusions and operative time were correlated with 30-day morbidity/mortality.

RESULTS

Pancreatoduodenectomy was completed in 4817 patients. RBC transfusions were given to 1559 (32%) patients (1-35 units). Overall morbidity and mortality rates were 37% and 3.0%, respectively. Overall 30-day morbidity increased in a stepwise manner with the number of RBC transfusions (R = 0.69, P < 0.01). Although RBC transfusions and operative times were not statistically linked (P = 0.87), longer operative times were linearly associated with increased 30-day morbidity (R = 0.79, P < 0.001) and mortality (R = 0.65, P < 0.01). Patients who were not transfused also displayed less morbidity (33%) and mortality (1.9%) (P < 0.05).

DISCUSSION

Peri-operative RBC transfusion after pancreatoduodenectomy is linearly associated with 30-day morbidity. Longer operative time also correlates with increased morbidity and mortality. Therefore, blood transfusions and prolonged operative time should be considered quality indicators for pancreatoduodenectomy.

A decade of experience with injuries to the gallbladder

BACKGROUND

Considering that injuries to the gallbladder are rare, the purpose of this study was to evaluate injury patterns, operative procedures and outcomes in patients with trauma to the gallbladder. A retrospective review of traumatic injuries to the gallbladder at an urban level 1 trauma center from 1996 to 2008 was performed. Injuries were identified via imaging or during operative exploration.

RESULTS

Injuries to the gallbladder occurred in 45 patients, 40 (89%) of whom suffered penetrating trauma. Associated injuries were present in 44 (98%) patients, including 10 (22%) pancreatic injuries requiring repair and/or drainage. Patients were severely injured (49% hemodynamically unstable at presentation; mean Injury Severity Score = 20; mean length of stay = 22 days; mortality rate = 24%). Cholecystectomy was performed in 42 patients (93%), while the remaining 3 had drainage only as part of a "damage control" operation related to their critical physiologic status. Injuries to the extrahepatic biliary ducts occurred in 3 patients (7%) as well. Although all patients developed trauma related complications, none were a direct result of their biliary tract injuries.

CONCLUSION

Injuries to the gallbladder are rare even in the busiest urban trauma centers. Almost all patients have associated intra-abdominal injuries, and nearly 50% of patients are hemodynamically unstable on admission. Rapid cholecystectomy is the treatment of choice for all mechanisms of injury, except when the first operative procedure is of the damage control type.

Blood loss in surgical oncology: neglected quality indicator?

Quality indicators can be defined as "specific and measurable elements of practice that can be used to assess the quality of care". Surgical blood loss is one of the most significant perioperative predictors of patient outcome. Blood loss is a modifiable quality indicator for oncologic cancer surgery. Surgical oncologists need to alter their surgical technique to promote bloodless surgery and decrease the variability in reported blood loss and rates of blood transfusion.

A phase II experience with neoadjuvant irinotecan (CPT-11), 5-fluorouracil (5-FU) and leucovorin (LV) for colorectal liver metastases

BACKGROUND

Chemotherapy may improve survival in patients undergoing resection of colorectal liver metastases (CLM). Neoadjuvant chemotherapy may help identify patients with occult extrahepatic disease (averting unnecessary metastasectomy), and it provides in vivo chemosensitivity data.

METHODS

A phase II trial was initiated in which patients with resectable CLM received CPT-11, 5-FU and LV for 12 weeks. Metastasectomy was performed unless extrahepatic disease appeared. Postoperatively, patients with stable or responsive disease received the same regimen for 12 weeks. Patients with progressive disease received either second-line chemotherapy or best supportive care. The primary endpoint was disease-free survival (DFS); secondary endpoints included overall survival (OS) and safety.

RESULTS

35 patients were accrued. During preoperative chemotherapy, 16 patients (46%) had grade 3/4 toxicities. Resection was not possible in 5 patients. One patient died of arrhythmia following surgery, and 1 patient had transient liver failure. During the postoperative treatment phase, 12 patients (55%) had grade 3/4 toxicities. Deep venous thrombosis (DVT) occurred in 11 patients (34%) at various times during treatment. Of those who underwent resection, median DFS was 23.0 mo. and median OS has not been reached. The overall survival from time of diagnosis of liver metastases was 51.6 mo for the entire cohort.

CONCLUSION

A short course of chemotherapy prior to hepatic metastasectomy may serve to select candidates best suited for resection and it may also direct postoperative systemic treatment. Given the significant incidence of DVT, alternative systemic neoadjuvant regimens should be investigated, particularly those that avoid the use of a central venous line.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00168155.

Population-based review of the outcomes following hepatic resection in a Canadian health region

BACKGROUND

Higher hospital and surgeon volumes have been associated with improved outcomes following hepatic resection; however, there appear to be additional factors that also play a role. The objective of our study was to examine the outcomes following hepatic resection over the past 13 years in a large urban Canadian health region.

METHODS

We used administrative procedure codes to identify all patients from 1991/92 to 2003/04 who underwent a hepatic resection in the Calgary health region, which has a referral base of about 1.5 million people. The primary outcome was operative mortality, defined as death before discharge.

RESULTS

There were 424 hepatic resections performed in the stated time period. Annual volume was stable until 2000, when it increased substantially. This corresponded to the formation of a multidisciplinary group that provided care to these patients. There were 25 deaths over the study period for a mean mortality of 5.9%. The mean length of stay in hospital was 14.6 (median 10) days. Over time, however, mortality steadily decreased. This corresponded to a concomitant increase in the volume of hepatic resections performed.

CONCLUSION

Over the past 13 years, the number of hepatic resections performed has increased; there has been a corresponding improvement in mortality rates. The improved rates are likely the result of multiple factors.

Rupture and intra-peritoneal bleeding of a hepatocellular carcinoma after a transarterial chemoembolization procedure: a case report

BACKGROUND

Transarterial chemoembolization (TACE) is a well accepted treatment for inoperable hepatocellular carcinoma (HCC). While minor complications involve 10% of all patients, severe complications are rare.

CASE PRESENTATION

We describe a case of a 90-year-old male with a large, superficial HCC who underwent TACE. He had a significant intraperitoneal bleed secondary to tumor rupture immediately following the procedure.

CONCLUSION

Tumor size and superficial location must be considered risk factors for tumor rupture and related complications.

Colorectal liver metastases contract centripetally with a response to chemotherapy: a histomorphologic study

BACKGROUND

Recently, there has been considerable interest in neoadjuvant chemotherapy for colorectal liver metastases. However, there is little information that defines how much liver should be removed after a favorable response.

METHODS

Liver metastases from 2 groups of patients were analyzed: 25 metastases were evaluated from a group that did not receive chemotherapy and 26 lesions were studied from patients who had received systemic chemotherapy before resection. All patients except for 1 had 5-fluorouracil (5-FU), leucovorin (LV), and irinotecan (CPT-11); 1 had 5-FU and LV alone. The average duration of chemotherapy was 2.9+/-0.7 months. Separate assessments of the histopathologic features of the central and peripheral portions of each tumor were made. The pathologist was blinded to all clinical information.

RESULTS

All of the untreated metastases had well-circumscribed borders. Irregular borders were seen in 6 of the postchemotherapy lesions (26%), which was particularly prominent in lesions that had significantly contracted. After chemotherapy, discrete islands of viable tumor cells outside of the main tumor mass were seen in 4 patients, but all were close to the peripheral margin of the tumor mass. Viable tumor cells were more frequent in the periphery of metastases, regardless of chemotherapy exposure. Central necrosis was prominent in untreated metastases, but disappeared after chemotherapy. In lesions treated with chemotherapy, central fibrosis was greater compared with untreated lesions.

CONCLUSIONS

After a partial response to chemotherapy, liver metastases shrank in a generally concentric fashion. These findings support the practice of removing less liver after downsizing with chemotherapy.

Colorectal liver metastases contract centripetally with a response to chemotherapy: a histomorphologic study

BACKGROUND

Recently, there has been considerable interest in neoadjuvant chemotherapy for colorectal liver metastases. However, there is little information that defines how much liver should be removed after a favorable response.

METHODS

Liver metastases from 2 groups of patients were analyzed: 25 metastases were evaluated from a group that did not receive chemotherapy and 26 lesions were studied from patients who had received systemic chemotherapy before resection. All patients except for 1 had 5-fluorouracil (5-FU), leucovorin (LV), and irinotecan (CPT-11); 1 had 5-FU and LV alone. The average duration of chemotherapy was 2.9+/-0.7 months. Separate assessments of the histopathologic features of the central and peripheral portions of each tumor were made. The pathologist was blinded to all clinical information.

RESULTS

All of the untreated metastases had well-circumscribed borders. Irregular borders were seen in 6 of the postchemotherapy lesions (26%), which was particularly prominent in lesions that had significantly contracted. After chemotherapy, discrete islands of viable tumor cells outside of the main tumor mass were seen in 4 patients, but all were close to the peripheral margin of the tumor mass. Viable tumor cells were more frequent in the periphery of metastases, regardless of chemotherapy exposure. Central necrosis was prominent in untreated metastases, but disappeared after chemotherapy. In lesions treated with chemotherapy, central fibrosis was greater compared with untreated lesions.

CONCLUSIONS

After a partial response to chemotherapy, liver metastases shrank in a generally concentric fashion. These findings support the practice of removing less liver after downsizing with chemotherapy.

Morbidity and mortality following multivisceral resections in complex hepatic and pancreatic surgery

Complex multivisceral resections in major hepatic and pancreatic surgery are relatively infrequent, and information regarding the morbidity and mortality associated with such resections is scant. The purpose of this paper is to describe the outcomes following such aggressive surgical treatment. A retrospective review of the outcomes following multiorgan resection in the setting of major liver or pancreatic resection was conducted from 2002 until July 2006. Patients who had a major hepatic or pancreatic resection plus resection of at least one other organ were included. The primary outcome measures analyzed were the postoperative morbidity and mortality. Secondary outcomes included recurrence rates and survival. Twenty-seven patients met the inclusion criteria. There were two postoperative deaths (7%). Complications occurred in 59% of patients. Complications were minor in 26% and severe in 33%. Complications were more frequent in older patients and in patients with pancreatic resections. Mortality was significantly increased in the setting of a pancreaticoduodenectomy. These more aggressive procedures should be considered to carry a higher risk of complications, particularly in patients undergoing pancreaticoduodenectomies. Patients should be selected carefully when undertaking complex multivisceral resections in major hepatic and pancreatic surgery.

Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy

Background

Pancreaticoduodenectomy is the primary treatment for periampullary cancer. Associated morbidity is high and often related to pancreatic anastomotic failure. This paper compares rates of pancreatic fistula, morbidity and mortality after pancreaticoduodenectomy in patients having reconstruction by pancreaticogastrostomy with those in patients having reconstruction by pancreaticojejunostomy.

Methods

A meta-analysis was performed of all large cohort and randomized controlled trials carried out since 1990.

Results

Eleven articles were identified for inclusion: one prospective randomized trial, two non-randomized prospective trials and eight observational cohort studies. The meta-analysis revealed a higher rate of pancreatic fistula associated with pancreaticojejunostomy reconstruction (relative risk (RR) 2·62 (95 per cent confidence interval (c.i.) 1·91 to 3·60)). A higher overall morbidity rate was also demonstrated in this group (RR 1·43 (95 per cent c.i. 1·26 to 1·61)), as was a higher mortality rate (RR 2·51 (95 per cent c.i. 1·61 to 3·91)).

Conclusion

Current literature suggests that the safer means of pancreatic reconstruction after pancreaticoduodenectomy is pancreaticogastrostomy, but much of the evidence comes from observational cohort study data.

Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review

BACKGROUND

Perforation related to endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication associated with significant morbidity and mortality. This study evaluated the management and outcomes of these perforations.

PATIENTS AND METHODS

Between July 1996 and December 2002, a total of 6620 ERCPs were performed at our regional endoscopy unit serving the 1.5 million population of Southern Alberta. Thirty perforations (0.45%) were identified and retrospectively reviewed. Results. Seven of these 30 patients were found to have guidewire perforations of the bile duct, 11 perforations were peri-ampullary, 3 duodenal, 1 esophageal, and 1 patient had a perforation of an afferent limb of a Billroth II anastomosis. In seven patients the location of the perforation could not be determined (unknown). All patients with guidewire perforations were recognized during ERCP, and all were managed medically. Of the 11 peri-ampullary perforations, 7 of these patients had a pre-cut sphincterotomy, 5 underwent surgery and 4 patients died. Delay in diagnosis occurred in all patients that died. Of the three duodenal perforations, all required operation and one patient died. Of the seven 'unknown' retroperitoneal perforations, two patients required surgery and there was no mortality. The patients with esophageal and afferent limb perforations both recovered uneventfully after surgery. Most patients who required surgery had retroperitoneal fluid seen on CT scanning.

CONCLUSIONS

We found that most guidewire perforations can be managed medically with little morbidity. Pre-cut sphincterotomy is a risk factor for perforation. Peri-ampullary and duodenal perforations have a high morbidity and mortality rate. In particular, retroperitoneal fluid collections on CT scans, delay in diagnosis and failure of medical therapy requiring salvage surgery are associated with poor outcomes. Early aggressive surgery may improve patient care.

Care plans for acutely deteriorating COPD: a randomized controlled trial

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for admission to hospital and are responsible for the majority of the direct economic costs of treating COPD.

AIMS

To test whether an individualized care plan for patients experiencing acute exacerbations of COPD result in reduced health care utilization and improved quality of life for patients.

METHODS

Ninety-two patients with confirmed COPD were selected by general practitioners or district nurses, and randomly assigned to care plan or usual care groups. The care plan was developed in collaboration with general practitioners, secondary care specialists, specialist nurses, ambulance service providers and the after hours clinic. Patients were followed for 12 months, and the primary end-points were frequency of use of primary care services and hospital admissions.

RESULTS

There was no significant reduction in hospital admissions or improvement in quality of life in the group of patients who used the care plan compared to controls. The care plan group called out the ambulance service more frequently [2.8 (1.3, 4.3) versus 1.1 (0.7, 1.5) calls per 12 months; P = 0.03], and there was a trend towards greater use of oral prednisone [2.3 (1.4, 3.2) versus 1.3 (0.8, 1.8) courses per 12 months; P = 0.06].

CONCLUSION

In contrast to asthma, the provision of individualized self-management plans, whose content was enhanced to provide guidance to carers and health care professionals, did not reduce health care utilization or improve overall quality of life during acute exacerbations of COPD. Other strategies are required.

Hepatic arterial infusion after curative resection of colorectal cancer metastases: a meta-analysis of prospective clinical trials

The use of hepatic arterial infusion (HAI) for the delivery of chemotherapeutic agents to treat residual microscopic disease after curative hepatic resection for colorectal cancer metastases remains controversial. In recent years, a number of studies examining adjuvant HAI have shown conflicting results. A meta-analysis of prospective clinical trials was performed to determine if adjuvant HAI confers a survival benefit in this setting. Two reviewers independently performed a literature search of MEDLINE, PubMed, EMBASE, the Cochrane library, and the Cochrane Clinical Trials Registry. Prospective clinical trials comparing hepatic arterial chemotherapy after curative hepatic resection for colorectal cancer metastases against a control arm were included. Non-English-language publications were excluded. The outcome measure was survival difference at 1 and 2 years after surgery. Seven studies met the inclusion criteria, and all except one were randomized trials. The survival difference in months (positive values favoring the treatment arm) was 1.8 at 1 year (95% confidence interval, -4.9, 8.5) and 9.6 at 2 years (95% confidence interval, -2.2, 21.4). Neither was statistically significant (at 2 years, P=0.11). Based on these findings, routine adjuvant HAI after curative resection for colorectal cancer of the liver cannot be recommended. However, given the trend toward a survival benefit at 2 years, further study is recommended.

Gallstone pancreatitis: does discharge and readmission for cholecystectomy affect outcome?

BACKGROUND

Conventional surgical wisdom is that a patient with gallstone pancreatitis should have the gallbladder removed during their initial hospitalization. However, patients are now often discharged to await operating room availability.

METHODS

A retrospective review of all cases of gallstone pancreatitis at the Foothills Hospital between 1992 and 1996 was undertaken. Patients with a first attack of mild gallstone pancreatitis were studied.

RESULTS

In all, 164 patients were identified: 90 patients were discharged for readmission cholecystectomy (discharged group), and 74 patients had the cholecystectomy before discharge (in-hospital group). Over the 5-year time period the proportion of patients discharged for readmission cholecystectomy increased from 27% to 67% (p<0.01). The total number of days waited for operation was greater in the discharged group versus in-hospital group: 40+/-69 days versus 8+/-10 days respectively (mean+/-SD). There was a trend towards an increased total number of days in hospital in the in-hospital group, 15.5+/-17 days versus 10.7+/-16 days. In the discharged group 20% (18 of 90) of patients experienced an adverse event requiring readmission while awaiting operation. Three had documented recurrent pancreatitis, 10 experienced recurrent pain, and 5 developed acute cholecystitis. There were no deaths in either group.

DISCUSSION

Twenty percent of patients with gallstone pancreatitis who are discharged to await operating room time (average wait 40 days) will require readmission for biliary symptoms.

Cystadenomas of the liver: a spectrum of disease

OBJECTIVES

To describe the wide variation in presentation of cystadenomas of the liver and to delineate useful tests for diagnosis and effective surgical treatment.

DESIGN

A case series.

SETTING

A university-affiliated hospital.

PATIENTS

Four patients (3 women, 1 man) having cystadenoma of the liver, 2 of whom had associated mesenchymal stroma.

MAIN OUTCOME MEASURES

Serum and cyst fluid carcinoembryonic antigen (CEA) and CA19-9 levels, type of surgery, morbidity and recurrence rates.

RESULTS

Cyst fluid CEA and CA19-9 levels were elevated. One patient had resection, 2 had complete enucleation and 1 had partial enucleation. There were no deaths. Morbidity included 1 wound infection; there were no biliary fistulas. The patient with partial enucleation had a radiologically confirmed recurrence.

CONCLUSIONS

Analysis of cyst fluid CEA and CA19-9 is useful for diagnosis; besides hepatic resection, complete enucleation should be considered as a reasonable treatment for patients with this disease.

Cystadenoma of the liver without mesenchymal stroma in a female following hormonal therapy for acne

BACKGROUND

Liver cystadenomas are relatively rare tumours that can be difficult to diagnose; treatment entails complete surgical extirpation either by either anatomical resection or enucleation.

CASE OUTLINE

A 19-year-old woman presented with acute onset of abdominal pain and was found to have a multilocular giant liver cyst.The cyst was percutaneously drained; CEA and CA 19-9 tumour markers were elevated in this cyst fluid: CEA 96 microg/L, CAI9-9 37 550 kU/L. The cyst was completely enucleated and has not recurred. Pathological examination confirmed a cystadenoma without mesenchymal stroma, and tumour oestrogen and progesterone receptors were negative.

DISCUSSION

This is the fourth report of a liver cystadenoma without mesenchymal stroma in a female and the first to document elevated cyst fluid tumour markers. This case also illustrates the possible relationship between hormonal therapy and tumour growth.

Non-heart-beating organ donors as a source of kidneys for transplantation: a chart review

BACKGROUND

Organ transplantation is the treatment of choice for patients with end-stage organ failure, but the supply of organs has not increased to meet demand. This study was undertaken to determine the potential for kidney donation from patients with irremediable brain injuries who do not meet the criteria for brain death and who experience cardiopulmonary arrest after withdrawal of ventilatory support (controlled non-heart-beating organ donors).

METHODS

The charts of 209 patients who died during 1995 in the Emergency Department and the intensive care unit at the Foothills Hospital in Calgary were reviewed. The records of patients who met the criteria for controlled non-heart-beating organ donation were studied in detail. The main outcome measure was the time from discontinuation of ventilation until cardiopulmonary arrest.

RESULTS

Seventeen potential controlled non-heart-beating organ donors were identified. Their mean age was 62 (standard deviation 19) years. Twelve of the patients (71%) had had a cerebrovascular accident, and more than half (10 [59%]) did not meet the criteria for brain death because one or more brain stem reflexes were present. At the time of withdrawal of ventilatory support, the mean serum creatinine level was 71 (29) mumol/L, mean urine output was 214 (178) mL/h, and 9 (53%) patients were receiving inotropic agents. The mean time from withdrawal of ventilatory support to cardiac arrest was 2.3 (5.0) hours; 13 of the 17 patients died within 1 hour, and all but one died within 6 hours. For the year for which charts were reviewed, 33 potential conventional donors (people whose hearts were beating) were identified, of whom 21 (64%) became donors. On the assumption that 40% of the potential controlled non-heart-beating donors would not in fact have been donors (25% because of family refusal and 15% because of nonviability of the organs), there might have been 10 additional donors, which would have increased the supply of cadaveric kidneys for transplantation by 48%.

INTERPRETATION

A significant number of viable kidneys could be retrieved and transplanted if eligibility for kidney donation was extended to include controlled non-heart-beating organ donors.

Mucinous cystadenoma of the appendix in a patient with systemic lupus erythematosus

A 38-year-old female with systemic lupus erythematosus presented with abdominal pain, diarrhea and iron-deficient anemia. Computed tomogram showed a 2 x 4 cm inhomogeneous lesion of the right adnexa. An unusual mass was identified extending from the appendiceal orifice at colonoscopy, and an 8 cm tubular appendix, apparently prolapsed into the cecum, was identified at celiotomy. An appendectomy with cecectomy was performed. On cut section, mucin was extruded from the lumen of the appendix. A mucinous neoplasm of the appendix with mucinous dissection to the serosal surface was reported at the time of frozen section. No gross ovarian pathology or peritoneal implants were noted. Cystadenoma with associated mucocele formation was verified by permanent histology. Mucocele of the vermiform appendix is a rare condition associated with neoplastic transformation in approximately 75% of all cases. Benign mucinous cystadenoma of the appendix should be differentiated from cystadenocarcinoma by frozen section at the time of celiotomy to ensure appropriate treatment. While systemic lupus erythematosus can lead to cutaneous mucinosis, an association with mucinous cystadenoma of the appendix has not been previously reported. Surveillance for metachronous colonic neoplasms is warranted in patients diagnosed with a mucinous neoplasm of the appendix.

Legislating organ donation: problems with this approach

The number of organs available for transplantation in Canada is insufficient to meet the demand, so many patients die waiting for surgery. Improving the supply of donor organs by enacting legislation is controversial. Three approaches to legislation have been suggested: required request, mandated choice, and presumed consent. Required-request legislation demands that physicians ask all families of potential donors for permission to retrieve organs. Mandated choice requires all adults to register whether they wish to be organ donors. Presumed consent allows the removal of organs without permission if no choice was registered. These laws are aimed at coercion of physicians, patients and families retrospectively, but their relative success and ethics are questionable. Facilitating the organ donation process may be a better solution.

Percutaneous versus open tracheostomy: a retrospective cohort outcome study

Percutaneous tracheostomy has been advocated as a faster, safer, and less invasive method of placing tracheostomy tubes in ventilated patients. To compare outcome differences, as measured by complication rates, between percutaneous and open tracheostomy, a retrospective cohort study was performed. All procedures were performed in the intensive care unit of a university-affiliated hospital. The minor complication rates did not differ significantly between percutaneous and open tracheostomy (12/31 vs. 12/29, respectively; p > 0.05), nor did there appear to be a difference in rates of major complications between the two groups (7/31 vs. 5/29; p > 0.05). This study identified a trend towards an increased risk of delayed airway loss in the percutaneous tracheostomy group.

Effects of liver transplantation on bile formation and biliary lipid secretion in the Sprague-Dawley rat

Altered hepatic secretory function after orthotopic liver transplantation constitutes a major perioperative clinical problem. Cholestasis and cholesterol gallstone formation are among the most frequent complications reported. Such changes in the allograft secretory function can be secondary to many factors like graft injury due to preservation and marked rejection, surgical complications, immunosuppressive therapy, and sepsis. The effects of liver transplantation per se on bile formation and biliary lipid secretion are unknown. The rat model of orthotopic liver transplantation was used to characterize better the true effect of transplantation without the influence of these confounding variables. Twenty-four-hour bile collections were performed on nine transplanted versus nine liver-denervated (sham) rats 4 weeks after surgery, and nine normal Sprague-Dawley rats. The liver allografts showed mild lymphocytic infiltration in portal tracts and the serum alanine transaminase levels were not significantly elevated. Bile flow and the secretion of bile salts and bilirubin under basal conditions were unchanged. Bile salt pool size, synthesis rate, and bile acid composition did not differ among the three groups. However, cholesterol secretion was dramatically reduced (50%) in the transplanted rats and decreased 31% in the liver-denervated rats (P < .001 and .01, respectively), resulting in a more favorable cholesterol saturation index (CSI = 0.29 for transplanted and 0.32 for sham versus 0.45 for normal controls; P < .01). Thus, liver transplantation with its attendant denervation did not impair hepatic secretory function, but rather improved biliary lipid composition despite mild rejection.