138 Endovascular Hepatic Artery Stents in The Modern Management of Post-Pancreatectomy Haemorrhage

Aim

Post-operative haemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on endovascular hepatic artery stents in the management of post-pancreatectomy haemorrhage.

Method

This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcome, contextualized by the clinical course of the denominator population. International Study Group for Pancreas Surgery (ISGPS) terminology was used for post-pancreatectomy haemorrhage.

Results

Sixty-seven (15%) had post-operative haemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; two-proportions test). Post-operative pancreatic fistulas were more frequent in the post-operative haemorrhage group (P = 0.029; two-proportions test). The median (IQR) delay between surgery and haemorrhage was 5 (2-14) days. Twenty-six required intervention comprising re-operation alone in 12, embolization alone in 5 and endovascular hepatic artery stent deployment in 5. Four further patients underwent multiple interventions with two having stents. Endovascular stent placement achieved initial haemostasis in 5 (72%). Follow-up was for a median (IQR) of 199 (145-400) days post-stent placement. In two patients the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 (8-22) days.

Conclusions

This study shows that in the specific setting of post-pancreatoduodenectomy haemorrhage with either a short remnant GDA bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important haemostatic option but is associated with a high risk of subsequent graft occlusion.

Liver resection and ablation for squamous cell carcinoma liver metastases

Background

Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS).

Method

Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS.

Results

Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30).

Conclusion

Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Improving care for patients with pancreatitis

Centralization may prove essential

Cardiopulmonary exercise testing for preoperative risk assessment before pancreaticoduodenectomy for cancer

OBJECTIVE

Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy.

METHODS

In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival.

RESULTS

A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ([Formula: see text] O 2 MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ([Formula: see text] E/[Formula: see text] CO 2) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95 % confidence interval [CI] 0.63-1.00, p = 0.020); a threshold of 41 was 75 % sensitive and 95 % specific (positive predictive value 50 %, negative predictive value 98 %). Above this threshold, raised [Formula: see text] E/[Formula: see text] CO 2 predicted poor long-term survival (hazard ratio 2.05, 95 % CI 1.09-3.86, p = 0.026).

CONCLUSIONS

CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived [Formula: see text] E/[Formula: see text] CO 2 predicts early postoperative death and poor long-term survival.

[Multidisciplinar international classification of the severity of acute pancreatitis: Italian version 2013]

AIM

The aim of this paper was to present the 2013 Italian edition of a new international classification of acute pancreatitis severity. The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. A global web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSION

This classification provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.

[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]

OBJECTIVE

To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation.

BACKGROUNDS

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity.

METHODS

A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

[Determinant-based classification of acute pancreatitis severity. International multidisciplinary classification of acute pancreatitis severity: the 2013 German edition]

OBJECTIVE

The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Thoracic surgical management of colorectal lung metastases: a questionnaire survey of members of the Society for Cardiothoracic Surgery in Great Britain and Ireland

INTRODUCTION

Distant metastases to liver and lung are not uncommon in colorectal cancer. Resection of metastases is accepted widely as the standard of care. However, there is no firm evidence base for this. This questionnaire survey was carried out to assess the current practice preferences of cardiothoracic surgeons in Great Britain and Ireland.

METHODS

An online questionnaire survey was emailed to cardiothoracic surgeons in Great Britain and Ireland. The survey was live for 12 weeks. Responses were collated with SurveyMonkey(®).

RESULTS

Overall, there were 75 respondents. The majority (83%) indicated thoracic surgery as a specialist interest. Almost all (99%) used thoracic computed tomography (CT) for staging; 70% added liver CT and 51% added pelvic CT. Fluorodeoxy-glucose positron emission tomography was used by 86%. The most frequent indication for pulmonary resection (97%) was solitary lung metastasis without extrathoracic disease. Video assisted thoracoscopic surgery (VATS) was used by 85%. In addition, thoracotomy was used by 96%. A third (33%) used radiofrequency ablation. Synchronous liver and lung resection was contraindicated for 83% of respondents. Over three-quarters (77%) thought that scientific equipoise exists presently for lung resection for colorectal lung metastases but only 21% supported a moratorium on this type of surgery until further evidence becomes available.

CONCLUSIONS

The results confirm that the majority of respondents use conventional cross-sectional imaging and either VATS or formal thoracotomy for resection. The results emphasise the continuing need for formal randomised trials to provide evidence of any survival benefit from pulmonary metastasectomy for colorectal lung metastases.

In vivo evaluation of the chitosan-based haemostatic agent Omni-stat® in porcine liver resection and in liver injury

BACKGROUND

Omni-stat®, a polysaccharide made by de-acetylation of chitin, is currently in use as a battlefield topical haemostat. This experimental study undertakes the first evaluation of Omni-stat in an in vivo porcine hepatectomy and liver trauma model.

METHODS

A model of sequential liver resection was employed: following liver resection, further resections were undertaken in the same animal provided that there was cessation of bleeding from the earlier resection and that haemodynamic stability was maintained. An additional liver trauma injury was undertaken after completion of all resections. Data were collected on heart rate, blood pressure, haematocrit, resection volumes, blood loss and the efficacy of Omni-stat in haemostasis.

RESULTS

Eight minor resections and 12 major resections were undertaken. Topical application of Omni-stat to raw post-transection surfaces immediately upon completion of resection achieved complete haemostasis with a single application in 14 of 15 (93%) resections. There was no recurrence of bleeding during the 5-hour protocol. The median time for cessation of bleeding after resection in the Omni-stat group was 3 min (range 3-6). This was not significantly different from time to cessation of bleeding in 5 control resections. There was no difference in blood loss or haemodynamic parameters. Respiratory rate was significantly faster after application of Omni-stat. In 2 liver lacerations, Omni-stat was effective in achieving cessation of haemorrhage.

CONCLUSION

Omni-stat is an effective haemostat in experimental in vivo porcine liver resection and liver trauma. Further evaluation is required to assess its physiological absorption profile in man and its comparative efficacy against commercially established agents.

Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection

BACKGROUND

Contemporary liver surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. This study evaluated preoperative cardiopulmonary exercise testing (CPET) in high-risk patients undergoing hepatic resection.

METHODS

In a prospective cohort referred for liver resection, patients aged over 65 years (or younger with co-morbidity) were evaluated by preoperative CPET. Data were collected prospectively on functional status, postoperative complications and survival.

RESULTS

Two hundred and four patients were assessed for hepatic resection, of whom 108 had preoperative CPET. An anaerobic threshold (AT) of 9·9 ml O(2) per kg per min predicted in-hospital death and subsequent survival. Below this value, AT was 100 per cent sensitive and 76 per cent specific for in-hospital mortality, with a positive predictive value (PPV) of 19 per cent and a negative predictive value (NPV) of 100 per cent: no deaths occurred above the threshold. Age and respiratory efficiency in the elimination of carbon dioxide (VE/VCO(2)) at AT were statistically significant predictors of postoperative complications. Receiver operating characteristic (ROC) curve analysis showed that a threshold of 34·5 for VE/VCO(2) at AT provided a specificity of 84 per cent and a sensitivity of 47 per cent, with a PPV of 76 (95 per cent confidence interval (c.i.) 58 to 88) per cent and a NPV of 60 (48 to 72) per cent for postoperative complications. Long-term survival of those with an AT of less than 9·9 ml O(2) per kg per min was significantly worse than that of patients with a higher AT (hazard ratio for mortality 1·81, 95 per cent c.i. 1·04 to 3·17; P = 0·036).

CONCLUSION

CPET provides a useful prognostic adjunct in the preoperative assessment of patients undergoing hepatic resection.

Impact of portal vein embolization on long-term survival of patients with primarily unresectable colorectal liver metastases (Br J Surg 2010; 97: 240–250)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer

BACKGROUND

Although many biochemical markers have been examined in pancreatic cancer none are definitive for pre-operative diagnosis. This systematic review examines studies using biochemical markers for the diagnosis of pancreatic cancer in order to appraise their role in contemporary management algorithms.

METHODS

A search of the MEDLINE database was undertaken using the key words pancreatic neoplasm and serum tumour marker. Only studies providing original data on sensitivity and specificity are included and data are presented on diagnostic accuracy, effect of cholestasis and the relation of tumour stage to blood levels of markers.

RESULTS

CA 19-9 is the most extensively evaluated with pooled data from 2283 patients. The median sensitivity of CA 19-9 for diagnosis is 79 (70-90%) and median specificity 82 (68-91%). CA 19-9 elevation in non-malignant jaundice results in a fall in specificity. Combination with other markers improves accuracy.

CONCLUSION

As the most extensively evaluated marker, CA 19-9 should be used in contemporary algorithms for the diagnosis of pancreatic cancer. Elevated values should be repeated after relief of jaundice.

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

BACKGROUND

Tumour clearance during pancreatectomy may be facilitated by resection of the portal-superior mesenteric vein, but this is associated with increased perioperative risk. There is no consensus about which patients benefit from portal-superior mesenteric vein resection.

METHODS

A systematic appraisal was carried out of the literature on portal-superior mesenteric vein resection during pancreatectomy to identify recurrent themes to guide management. A computerized search of the Medline and Embase databases found 52 non-duplicated studies providing relevant data in 1646 patients. Pooled data were examined for information on outcome categories relating to operation, complications, histopathology and overall outcome.

RESULTS

The median (range) number of patients with portal-superior mesenteric vein resection per cohort was 23 (4-172). Median operating time was 513 (168-1740) min and blood loss 1750 (300-26000) ml. Postoperative morbidity ranged from 9 to 78 per cent with a median per cohort of 42 per cent. There were 73 perioperative deaths (5.9 per cent of 1235 for whom mortality data were provided). Median survival was 13 months, and 1-, 3- and 5-year survival rates were 50, 16 and 7 per cent respectively. Specimen histopathology confirmed positive nodes in 67.4 per cent.

CONCLUSIONS

This is the largest collective report to date on portal-superior mesenteric vein resection in pancreatectomy. The high rate of nodal metastases and low 5-year survival rates suggest that by the time of tumour involvement of the portal vein cure is unlikely, even with radical resection.

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

BACKGROUND

Tumour clearance during pancreatectomy may be facilitated by resection of the portal-superior mesenteric vein, but this is associated with increased perioperative risk. There is no consensus about which patients benefit from portal-superior mesenteric vein resection.

METHODS

A systematic appraisal was carried out of the literature on portal-superior mesenteric vein resection during pancreatectomy to identify recurrent themes to guide management. A computerized search of the Medline and Embase databases found 52 non-duplicated studies providing relevant data in 1646 patients. Pooled data were examined for information on outcome categories relating to operation, complications, histopathology and overall outcome.

RESULTS

The median (range) number of patients with portal-superior mesenteric vein resection per cohort was 23 (4-172). Median operating time was 513 (168-1740) min and blood loss 1750 (300-26000) ml. Postoperative morbidity ranged from 9 to 78 per cent with a median per cohort of 42 per cent. There were 73 perioperative deaths (5.9 per cent of 1235 for whom mortality data were provided). Median survival was 13 months, and 1-, 3- and 5-year survival rates were 50, 16 and 7 per cent respectively. Specimen histopathology confirmed positive nodes in 67.4 per cent.

CONCLUSIONS

This is the largest collective report to date on portal-superior mesenteric vein resection in pancreatectomy. The high rate of nodal metastases and low 5-year survival rates suggest that by the time of tumour involvement of the portal vein cure is unlikely, even with radical resection.

Hyperlipidaemia and outcome in acute pancreatitis

There is a well-recognised association between hyperlipidaemia and acute pancreatitis. However, the role of hyperlipidaemia in modulating disease course is not clear. The aim of the study was to conduct a prospective study in acute pancreatitis to assess the relation between hyperlipidaemia and disease severity using current disease descriptors. The study population constituted 43 patients with acute pancreatitis, admitted during the calendar year 2001. There were 19 (44%) males. The median (range) age was 50 (21-86) years. Serum triglycerides, cholesterol and high-density lipids were measured on admission. Patients were followed-up for at least 6 months after discharge. Principal outcomes were relation between hyperlipidaemia and peri-pancreatic complications and end-of-episode disease severity. The results showed that hypertriglyceridaemia was present in 14 patients (33%). There was a significant difference in mean (SEM) serum triglyceride levels between patients with alcohol-induced pancreatitis compared with pancreatitis of other aetiologies [3.07 (1.0) mmol/l vs. 1.26 (0.11) mmol/l; p = 0.03, Fisher's exact test]. There was no correlation between admission hypertriglyceridaemia and admission APACHE II score (r(2) = 0.0015). Similarly, there was no correlation between triglyceride level and either pancreatic inflammatory complications or final outcome. In conclusion, this study has demonstrated that there was no significant correlation between hypertriglyceridaemia and either complications of disease or overall end-of-episode severity in this population of patients with acute pancreatitis.

Strategic management of severe acute pancreatitis in the Jehovah's witness

Haemorrhage can be a lethal complication of severe acute pancreatitis. Management includes identification and control of the source of bleeding and supportive therapy such as blood transfusion. Individuals who refuse transfusion on the grounds of religious belief can provide a further major challenge. The management in these individuals can be focused from the outset with a strategy that aims to avert anaemia and transfusion. This article reports a case of severe acute pancreatitis in a woman of the Jehovah's Witness faith. The episode was complicated by infected pancreatic necrosis requiring surgical intervention. Careful strategic planning is critical to the management of severe acute pancreatitis in patients of the Jehovah's Witness faith. In this case, acute pancreatitis complicated by infected necrosis was successfully managed by the use of preoperative erythropoietin, venesection using paediatric blood vials, meticulous intraoperative attention to haemostasis and the use of adjunctive intraoperative techniques such as argon diathermy.

Intravenous antioxidant modulation of end-organ damage in L-arginine-induced experimental acute pancreatitis

BACKGROUND

Oxidative stress mediates acinar injury in experimental acute pancreatitis (AP) and antioxidants are depleted in human AP. This study tests the hypothesis that exogenous antioxidant supplementation ameliorates experimental AP.

METHODS

Male Sprague-Dawley rats were randomly allocated to 1 of 4 groups (n = 5/group) and sacrificed at 72 h. AP was induced by 250 mg per 100 g body weight of 20% L-arginine hydrochloride in 0.15 mol/l sodium chloride. Group allocations were: group 1 (control) no intervention; group 2 AP; group 3 early multiple antioxidant (MAOX) intervention comprising 15 microg/kg selenium, 30 microg/kg ascorbate and 300 mg/kg N-acetylcysteine given at 6 and 30 h and group 4 the MAOX combination above given at 24 and 48 h. Endpoints were: serum amylase, antioxidant levels, bronchoalveolar lavage (BAL) protein and lung myeloperoxidase (MPO) activity and histological assessment of pancreatic injury.

RESULTS

L-arginine induced AP characterised by oedema, neutrophil infiltration, acinar cell degranulation and elevated serum amylase. Early MAOX reduced pulmonary MPO and BAL protein and reduced acinar swelling, degranulation and pancreatic parenchymal infiltration by inflammatory cells. These features were absent when intervention was delayed.

CONCLUSION

In this model, early but not late antioxidant intervention ameliorates pancreatic and pulmonary injury.

Trends in fungal colonization of pancreatic necrosis in patients undergoing necrosectomy for acute pancreatitis

BACKGROUND

This study examines fungal colonization of post-inflammatory pancreatic necrosis in a cohort of patients undergoing open surgical necrosectomy in a single, tertiary referral unit over a 10-year period.

METHODS

The charts of all patients with acute pancreatitis who underwent surgical necrosectomy during the period January 1992 to December 2001 were examined. Following exclusions a population of 30 patients were identified. There were 18 men with a median (range) age of 42 (20-69) years. Sixteen (53%) underwent surgery because of positive fine needle aspirates and the remainder underwent surgery on clinical grounds. Twenty-nine (97%) received antibiotics prior to necrosectomy. Principal outcomes were the results of microbiological culture with reference to isolation of fungi, site of isolates, trends in colonization and outcome.

RESULTS

Candida were cultured from pancreatic necrosis in 5 (17%). These 5 individuals also had positive candidal cultures from sputum or bronchial aspirates. There were no deaths in patients with fungal colonization of necrosis. There was no change in the annual incidence of fungal colonization of necrosis over the study period.

CONCLUSION

Although this is a small study, there are two consistent observations: mortality in fungal colonization of necrosis was low and there was no change in the annual incidence of fungal colonization of necrosis over the decade. Discrepancies between these findings and those of previous reports mandate larger prospective evaluation.

Development of procedure-specific patient information sheets for acute abdominal surgery and validation in patients undergoing urgent cholecystectomy or appendicectomy

This prospective study was carried out in three related phases. In phase I, the information needs perceived by a cohort of 49 patients undergoing urgent abdominal surgery were assessed postoperatively and areas of perceived deficiency identified. In phase II, information provided by consultant surgeons caring for these patients was assessed. This information was then integrated with material gained from insurance companies and governmental organisations on issues such as return to driving in order to generate procedure-specific information sheets for appendicectomy and urgent cholecystectomy. In phase III, these information sheets were validated by a separate cohort undergoing these procedures. Key findings from the patients' perspective were, first, there remains an unmet need for basic information about the impact of urgent abdominal surgery on daily activity. Second, there is a striking variation in the information provided by consultant surgeons. Third, procedure-specific information sheets fulfil an important role in satisfying the patients' information requirements.

Intravenous n-acetylcysteine, ascorbic acid and selenium-based anti-oxidant therapy in severe acute pancreatitis

BACKGROUND

To observe outcome in a cohort of patients with severe acute pancreatitis receiving multiple anti-oxidant therapy.

METHODS

An observational study was carried out in 46 consecutive patients with acute pancreatitis fulfilling current Atlanta consensus criteria for severe disease. All patients received multiple anti-oxidant therapy based on intravenous selenium, N-acetylcysteine and ascorbic acid plus beta-carotene and alpha-tocopherol delivered via nasogastric tube. Principal outcomes were the effect of anti-oxidant supplementation on anti-oxidant levels, morbidity and mortality in patients on anti-oxidant therapy, case-control analysis of observed survival compared to predicted survival derived from logistic organ dysfunction score (LODS), logistic regression analysis of factors influencing outcome and side effect profile of anti-oxidant therapy.

RESULTS

Paired baseline and post-supplementation data were available for 25 patients and revealed that anti-oxidant supplementation restored vitamin C (P = 0.003) and selenium (P = 0.028) toward normal. In univariate survival analysis, patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 12.6% for each unit increase (95% CI 6.0% to 19.6%). The mean LODS calculated on admission to hospital was 3.7 (standard error of the mean 4.1) giving a predicted mortality for the cohort of 21%. The observed in-hospital mortality was 43%.

CONCLUSIONS

Case-control analyses do not appear to demonstrate any benefit from the multiple anti-oxidant combination of selenium, N-acetylcysteine and ascorbic acid in severe acute pancreatitis.

Intractable pruritus associated with insulinoma in the absence of multiple endocrine neoplasia: a novel paraneoplastic phenomenon

Insulinoma is a rare tumour, the main symptoms of which are related to hypoglycaemia. Generalized pruritus has been described in association with the multiple endocrine neoplasia syndrome (MEN II or Sipple's syndrome) as a paraneoplastic phenomenon. Further, pruritus is known to be part of the paraneoplastic syndrome in other solid tumours. This case describes a patient presenting with symptoms of Whipple's triad (hypoglycaemic symptoms during fasting, low fasting blood sugar levels and symptoms relieved by intravenous dextrose). Magnetic resonance scanning and selective mesenteric angiography demonstrated a probable pancreatic neuroendocrine tumour. Pituitary fossa imaging and endocrine profile excluded the MEN I syndrome. Symptoms resolved after surgical removal of the tumour. Histology confirmed a pancreatic neuroendocrine tumour. The association between pruritus and insulinoma appears to be a novel paraneoplastic phenomenon.

End-stage chronic pancreatitis: a practical disease-descriptor

BACKGROUND

Contemporary classification systems for chronic pancreatitis do not incorporate current knowledge of the disease biology of this condition.

METHOD AND RESULTS

This paper presents three case summaries of patients with longstanding chronic pancreatitis with extra-pancreatic complications. The cases highlight the inadequacies of current terminology. The term "end-stage chronic pancreatitis" is applied to advanced disease and disease descriptors are defined.

CONCLUSION

The term "end-stage chronic pancreatitis" is a practical and readily applicable disease descriptor.

A simplified method for computed tomographic estimation of prognosis in acute pancreatitis

BACKGROUND

Computed tomography is valuable for the diagnosis of acute pancreatitis. Although CT-based prognostic scoring systems are available, they are complex and impractical for routine clinical use. We examined the validity of a simplified CT-based scoring system in a cohort of patients with acute pancreatitis.

METHOD

Observational study based on correlation of CT findings with clinical outcomes. Seventy patients admitted to the Royal Infirmary of Edinburgh from January 1991 to December 1997 with a diagnosis of acute pancreatitis and undergoing CT with intravenous contrast during the first 3 to 10 days after admission were included in the study.

RESULTS

Multivariate logistic regression analysis demonstrated that the finding of mesenteric oedema and free peritoneal fluid on CT were independent early predictive factors of adverse outcome. Allocating one point each for either mesenteric oedema (MO) or peritoneal fluid (P) (giving a maximum score of 2), a simple MOP score was derived. Compared with the Glasgow and APACHE multiple-factor scoring systems and the Helsinki and Balthazar CT-based scoring systems areas under ROC curves were: admission Apache II 0.57, admission Glasgow 0.62. Balthazar score 0.79, Helsinki score 0.85 and MOP score 0.87.

CONCLUSIONS

The presence of mesenteric oedema or peritoneal fluid on CT appears to be a simple and widely applicable predictor of disease severity in acute pancreatitis.

Extra-pancreatic end-to-side hepaticojejunostomy: a practical modification of the duodenum-preserving pancreatic head resection (DPPHR) for chronic pancreatitis

BACKGROUND

Duodenum-preserving pancreatic head resection (DPPHR) is recognised for the surgical treatment of chronic pancreatitis. Approximately 15-20% of patients undergoing DPPHR require a synchronous biliary drainage procedure for stricture.

METHODS AND RESULTS

This report describes a technical modification involving the placement of an extra-pancreatic end-to-side Roux hepaticojejunostomy utilising the same jejunal loop employed for pancreaticojejunal anastomosis.

DISCUSSION

Extra-pancreatic end-side hepaticojejunostomy is a simple technical modification of DPPHR. The biliary anastomosis is constructed according to the well-established principles of biliary reconstruction and represents a safe and valuable technical option.

Outcome of necrosectomy in acute pancreatitis: the case for continued vigilance

BACKGROUND

Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of mortality and may be influenced by a range of variables including patterns of referral, case selection and quality of care.

METHODS

An observational study of a consecutive series of 54 patients undergoing pancreatic necrosectomy in a specialist Hepatobiliary unit over an 8-year study period. Principal outcomes were organ dysfunction and physiological derangement in relation to surgery, microbial colonization of necrosis and relation to outcome, re-operation rates, requirement for peri-operative nutritional support, trends in mortality and survival analysis.

RESULTS

Necrosectomy was associated with statistically significant deterioration in immediate postoperative organ dysfunction scores (ANOVA P < 0.01). Infected necrosis was present in 36 (68%). Fungal colonization of necrosis was present in 5 (9%). Mortality in this subgroup was 80% (4 deaths). There was no association between bacterial colonization of necrosis and death in this study (P = 0.77; Fisher exact test; relative risk 0.9,95% confidence interval 0.54-1.54). Twenty patients (37%) required further surgical intervention with an average of 1.5 surgical procedures per patient. Twenty-three patients (43%) died. Patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 14% for each unit increase in APACHE-II score at admission.

CONCLUSIONS

The results of the present study illustrate that there is no place for complacency in the surgical management of patients with severe acute pancreatitis. A clinical governance approach would promote pre-defined protocols between admitting hospitals and tertiary referral centres. Future research should target new interventions in patients with high admission APACHE-II scores in whom prognosis is particularly poor and explore the role of infection of necrotic tissue.

Small-bowel obstruction secondary to subcutaneous small-bowel entrapment: a late complication of laparostomy for necrotizing pancreatitis

Laparostomy is a well recognized strategy for the management of patients who have necrotizing pancreatitis and may require multiple re-intervention. The open wound can be left to heal through a process of granulation and contraction. This article describes intestinal obstruction secondary to entrapment of a loop of small bowel within the cicatrix of the contracting cutaneous scar. An awareness of the potential for entrapment of the small bowel in the healing scar is critical for clinicians using laparostomy in the management of acute necrotizing pancreatitis.

Variations in implementation of current national guidelines for the treatment of acute pancreatitis: implications for acute surgical service provision

OBJECTIVES

The aim of this study was to explore the implementation of the current national guidelines for the treatment of acute pancreatitis. By taking pooled data from all available individual and regional audits, the study aimed to identify areas of consistent variance from the 'best practice' stipulated in the guidelines.

METHODS

All published audits of the management of acute pancreatitis where treatment was compared to the current British Society of Gastroenterology guidelines for the treatment of acute pancreatitis were identified from a search of MEDLINE and the published abstracts of relevant specialty meetings.

RESULTS

Five audits providing pooled data on 545 patients were identified. Overall mortality from severe disease was 8% (range, 4-17%). Definitive treatment of gallstone disease within 4 weeks of index attack was performed in 49% (range, 16-65%). High dependency or intensive care facilities for severe disease were available in 52% (range, 20-100%).

CONCLUSION

This study demonstrates the presence of striking variations in the implementation of the current national guidelines for the treatment of acute pancreatitis.

Proximal gastric diverticulum after anterior lesser curve seromyotomy

A case of gastric diverticulum arising in a patient who had previously undergone anterior lesser curve seromyotomy for chronic duodenal ulcer disease is reported. The endoscopic appearance of this lesion is described and the potential mechanisms of causation are reviewed. The clinical relevance of this rare finding is examined with emphasis on the need for an index of awareness of this abnormality on the part of endoscopists and in particular, on the risks of injudicious biopsy of such a diverticulum.

Hypopharyngeal perforation: an uncommon cause of pneumoperitoneum

Endotracheal intubation is common practice being performed both electively and as an emergency. Complications of this procedure are uncommon. A case is described of hypopharyngeal rupture after emergency intubation that presented with a pneumoperitoneum. The clinical signs, relevant investigations and management options are discussed for this injury and the need is emphasised for a high index of suspicion in order to make an early diagnosis.

Value of angiographic embolisation for the control of major haemorrhage after oesophagogastric or pancreaticobiliary surgery

OBJECTIVE

To assess the effectiveness of selective mesenteric angiography in finding the bleeding point in patients with haemorrhage after upper gastrointestinal operations, and the efficacy of angiographic haemostasis in controlling haemorrhage.

DESIGN

Open study.

SETTING

University teaching hospital in the United Kingdom.

SUBJECTS

6 patients who required urgent investigation for haemorrhage after elective oesophagogastric or pancreaticobiliary operations.

INTERVENTION

Mesenteric angiography.

MAIN OUTCOME MEASURES

Identification of bleeding point and control of haemorrhage.

RESULTS

Mesenteric angiograms were done at a median of 20 days (range 3-49) after operation and identified the site of bleeding in all 6 patients. Definitive control of bleeding was achieved by embolisation in 2. Further attempts at angiographic embolisation failed to control the bleeding in the other 4.

CONCLUSION

Mesenteric angiography appears to be a valuable investigation in patients with postoperative bleeding after upper gastrointestinal operations. Angiographic embolisation may help to obtain haemostasis, and may stabilise a critically ill patient to allow time for more controlled assessment and treatment.

Endothelial-derived selectins in the development of organ dysfunction in acute pancreatitis

OBJECTIVE

The development of organ dysfunction is the principal determinant of outcome in acute pancreatitis and is mediated through a systemic inflammatory response characterized by leukocyte and endothelial cell activation. Up-regulation of the endothelial cell adhesion molecules, E-selectin and P-selectin, is important for endothelial/leukocyte interactions. Levels of serum-soluble E-selectin and P-selectin have been suggested as markers of endothelial activation. This study examines the kinetics of serum-soluble selectins in patients with acute pancreatitis complicated by organ dysfunction.

DESIGN

Prospective observational study.

SETTING

University teaching hospital with a specialist hepato-pancreatico-biliary service.

PATIENTS

Eighteen patients with acute pancreatitis were studied, nine of whom had organ dysfunction.

MEASUREMENTS AND MAIN RESULTS

Serial venous blood samples were collected on the first 3 days after admission for measurement of soluble E-selectin and P-selectin by enzyme-linked immunosorbent assay. In all patients, soluble P-selectin concentrations decreased significantly during the study period. Nonsurvivors had significantly higher levels of soluble P-selectin than survivors. In contrast, soluble E-selectin increased significantly during the study period in patients with organ dysfunction, whereas it remained constant in patients without evidence of organ dysfunction.

CONCLUSIONS

These results suggest a role for endothelial-derived selectins in the development of organ dysfunction in patients with acute pancreatitis. The observed temporal differences in serum selectin concentrations is in keeping with in vitro observations of endothelial selectin expression.

The process of informed consent for urgent abdominal surgery

OBJECTIVES

To assess perceptions of the informed consent process in patients undergoing urgent abdominal surgery.

DESIGN

A prospective observational study was carried out using structured questionnaire-based interviews. Patients who had undergone urgent abdominal surgery were interviewed in the postoperative period to ascertain their perceptions of the informed consent process. Replies were compared to responses obtained from a control group undergoing elective surgery, to identify factors common to the surgical process and those specific to urgent surgery. Patients' perceptions of received information were also compared to the information perceived to have been provided by the consent obtainers.

SETTING

Gastrointestinal surgical service of a university teaching hospital.

PATIENTS

Seventy-four consecutive patients undergoing urgent abdominal surgery and 80 control patients undergoing elective surgery.

MAIN MEASUREMENTS

Principal outcome measures were patients perceptions of factors interfering with the ability to give informed consent, assessment of the quality of informed consent and the degree of discussion of the expected outcomes.

RESULTS

Forty-nine of the seventy-four (66%) patients undergoing urgent surgery perceived that pain did not affect their ability to give informed consent. Twenty-seven reported an adverse effect of analgesia on the ability to give informed consent. Only 22% of patients undergoing urgent surgery perceived that there had been any discussion of potential side effects and complications of surgery.

CONCLUSION

The majority of patients in this series with acute intra-abdominal surgical conditions perceive that they retain the ability to give informed consent for surgery. There is a need for improved discussion of therapeutic options and likely outcomes.

Evidence against a role for polymorphisms at tumor necrosis factor, interleukin-1 and interleukin-1 receptor antagonist gene loci in the regulation of disease severity in acute pancreatitis

BACKGROUND

Cytokines such as tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) and their endogenous antagonists such as IL-1 receptor antagonist (IL-1RA) are important mediators of disease severity in acute pancreatitis. Because the level of secretion of these cytokines is determined in part by genetic factors, the aim of this study was to examine the influence of genetically determined cytokine secretion upon disease severity in acute pancreatitis.

METHODS

TNF (TNF-308, TNFB), IL-1beta, and IL-1 receptor antagonist (IL-1RA) genotypes were determined for 190 patients with acute pancreatitis and 102 healthy volunteers. To further assess the influence of genetic factors, the cytokine phenotype for TNF-alpha, IL-1beta, and IL-1RA was determined by using a whole blood culture technique in 51 patients after recovery.

RESULTS

The distributions of TNF-308, TNFB, IL-1beta, and IL-1RA gene polymorphisms were similar in patients with mild or severe acute pancreatitis. Further, no difference in gene polymorphism frequencies was observed between patients with acute pancreatitis and healthy controls. With respect to phenotype, the secretion of TNF-alpha was similar in patients with previous mild and severe acute pancreatitis; however, the IL-1beta: IL-1RA ratio was significantly lower in patients with previous severe acute pancreatitis than in those with mild disease.

CONCLUSIONS

Our observations suggest that genetic factors are not important in determining TNF-alpha secretion in patients with acute pancreatitis. However, a predetermined imbalance between IL-1beta and its antagonist IL-1RA would appear to exist in patients with severe acute pancreatitis, although the genetic basis for this altered relationship could not be determined.

Standards of documentation of the surgeon-patient consultation in current surgical practice

BACKGROUND

This study was designed to assess the reliability of the system whereby junior doctors document the surgeon-patient consultation in general surgical practice in the UK.

METHODS

A prospective observational study was carried out, with an independent observer recording details of the surgeon-patient consultation and assessing the reliability of documentation. An exact record of the information given by consultants was transcribed in shorthand at the time of consultation. Data were recorded in the categories recommended for notation by the General Medical Council: clinical findings, decisions made, information given to patient and treatment prescribed. Case notes were examined within 24 h of the ward round to ascertain reliability of the documentation.

RESULTS

The study population comprised 432 surgeon-patient consultations. There were important deficiencies in the documentation of consultants' clinical findings and management decisions. In addition, information given by consultants to the patients regarding clinical findings and treatment planned (including the need for operation) was recorded in a median of 6 per cent of consultations.

CONCLUSION

This study provides objective evidence of shortfalls in the documentation of the surgeon-patient consultation process. These deficiencies are such that, under present circumstances, the requirements of the General Medical Council with respect to case note documentation are not fulfilled in this setting.

Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis

BACKGROUND

Recent evidence suggests that intestinal dysfunction has a role in sustaining the systemic inflammatory response in acute pancreatitis and may be ameliorated by the introduction of enteral nutrition. This study therefore assessed the effect of early enteral nutrition on the systemic inflammatory response in patients with prognostically severe acute pancreatitis.

METHODS

Patients with prognostically severe acute pancreatitis within 72 h of disease onset were randomized to receive either enteral nutrition or conventional therapy consisting of a nil-by-mouth regimen. Serum interleukin (IL) 6, soluble tumour necrosis factor receptor I (sTNFRI) and C-reactive protein (CRP) were used as markers of the inflammatory response. Intestinal function was assessed using a differential sugar permeability technique.

RESULTS

Of 27 patients, 13 received enteral nutrition. A median of 21 (range 0-100) per cent of calorific requirements was delivered over the first 4 days by enteral nutrition. There were no significant complications of enteral nutrition. The introduction of enteral nutrition did not affect the serum concentrations of IL-6 (P = 0.28), sTNFRI (P = 0.53) or CRP (P = 0.62) over the first 4 days of the study. Although there were no significant differences in intestinal permeability between the two patient groups at admission (chi2 = 2.33, d.f. = 1, P = 0.13), by day 4 abnormal intestinal permeability occurred more frequently in patients receiving enteral nutrition (chi2 = 4.94, d.f. = 1, P = 0.03)

CONCLUSION

Early enteral nutrition did not ameliorate the inflammatory response in patients with prognostically severe acute pancreatitis. Furthermore, it did not have a beneficial effect on intestinal permeability. Presented in part to the Pancreatic Society of Great Britain and Ireland in Leeds, UK, November 1998 and at Digestive Disease Week in Orlando, Florida, USA, May 1999

Angiographic embolization for major haemorrhage after upper gastrointestinal surgery

AIMS: Severe postoperative haemorrhage after upper gastrointestinal surgery is a serious complication. This study examined the effectiveness of selective mesenteric angiography (SMA) in localizing a bleeding point and the ability of angiographic haemostatic methods to control bleeding. METHODS: The case notes of a consecutive series of nine patients undergoing urgent SMA during 1996-1998 were analysed. Examination of angiography suite records confirmed the accuracy of patient identification. SMA was performed 18 times with 13 embolizations in nine individuals (seven men; median age 54 (27-73) years). Patients underwent the following operations: Whipple pancreaticoduodenectomy (four patients), pancreatic necrosectomy (two), total gastrectomy (one), cholecystectomy (one) and splenectomy (one). The median interval from surgery to haemorrhage was 15 (2-49) days. Six patients presented with haematemesis/melaena and three with bleeding from drains. Seven had evidence of shock (systolic blood pressure less than 100 mmHg, pulse more than 100 per min); the mean preprocedure haemoglobin concentration was 59 g/l. A median of 8 (4-14) units of blood were transfused before embolization and 4 (2-9) units after. Ten initial endoscopies were performed in six patients, seven of which revealed a source of bleeding. Endoscopic haemostasis was attempted in five and achieved temporary control of bleeding in two. RESULTS: Angiography revealed a discrete bleeding point in 13 of 18 procedures in eight patients. Where a bleeding point was identified, angiographic embolization using 3-8-mm stainless steel coils (ten) or a combination of coils and gelatin sponge (three) achieved radiological evidence of haemostasis in all cases. Periprocedural complications occurred in one patient with unintentional partial embolization of the right hepatic artery during embolization of an actively bleeding left hepatic artery pseudoaneurysm. Rebleeding occurred in six patients within 48 h. Three rebleeds were successfully managed with repeat SMA and embolization (one patient required a third embolization); the remaining three required surgery. Definitive radiological haemostasis was achieved in six patients. Five of the nine patients died in hospital, two of whom had been successfully embolized. CONCLUSIONS: In this group of patients, endoscopy contributed relatively little to treatment of postoperative haemorrhage. In contrast, SMA identified a bleeding point in eight of nine patients and achieved definitive control of bleeding in six. SMA and embolization appears to have a useful role in patients with this infrequent but potentially lethal complication.

Survey of antibiotic prophylaxis in acute pancreatitis in the UK and Ireland

BACKGROUND

Current surgical practice with regards to antibiotic prophylaxis in acute pancreatitis in the UK and Ireland was overviewed.

METHODS

The 1103 members of the Association of Surgeons of Great Britain and Ireland were surveyed by postal questionnaire. A total of 528 replies were received (48 per cent). Following exclusion of surgeons not treating patients with acute pancreatitis, analysis was carried out on 429 replies.

RESULTS

Respondents treated a median of 12 (interquartile range (i.q.r.) 10-20) patients per year with acute pancreatitis. Prophylactic antibiotic therapy was used by 88 per cent of responding surgeons, of whom 24 per cent used it in all cases. For surgeons professing selective use of antibiotics, the most common indication for use was in patients with prognostically severe disease. A cephalosporin was prescribed in 72 per cent of patients; cefuroxime was the single most common antibiotic. Combination therapy with metronidazole was used in 48 per cent of attacks. The median duration of antibiotic therapy was 5 (i.q.r. 5-7) days. An adverse drug reaction attributable to the use of prophylactic antibiotics was reported by 11 per cent of respondents.

CONCLUSION

This study has established that a significant body of clinicians charged with the responsibility of treating acute pancreatitis use antibiotic prophylaxis in the initial treatment of patients with predicted severe disease.