The Impact of a Dedicated "Hot List" on the In-Patient Management of Patients With Acute Gallstone-Related Disease

Background: Index admission laparoscopic cholecystectomy is the standard of care for patients admitted to hospital with symptomatic acute cholecystitis. The same standard applies to patients suffering with mild acute biliary pancreatitis. Operating theatre capacity can be a significant constraint to same admission surgery. This study assesses the impact of dedicated theatre capacity provided by a specialist surgical team on rates of index admission cholecystectomy.

Methods: This clinical cohort study compares the management of patients with symptomatic gallstone disease admitted to a tertiary care university teaching hospital over two equal but chronologically separate time periods. The periods were before and after service reconfiguration including a specialist HPB service with dedicated operating theatre time allocation.

Results: There was a significant difference in the number of admissions over the two time periods with a greater proportion of patients having index admission surgery in the second time period with correspondingly fewer having more than one admission during this latter time period. In the second time period 43% of patients underwent index admission cholecystectomy compared to 23% in the first (P < 0.001). The duration of surgery was shorter for patients undergoing surgery during the second time period [135 (102–178) min in the first period and in the second period 106 (89–145) min] (P = 0.02).

Discussion: This paper shows that the concentration of theatre resources and surgical expertise into regular theatre access for patients undergoing urgent laparoscopic cholecystectomy is an effective and safe model for dealing with acute biliary disease.

Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy

OBJECTIVES

Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF.

METHODS

A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140).

RESULTS

Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF.

CONCLUSIONS

Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.

Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery

BACKGROUND

Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery.

METHODS

Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures.

RESULTS

One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events.

DISCUSSION

CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.