Management of Complicated Acute Pancreatitis: The Role of Hub-and-Spoke Model.

OBJECTIVE: To determine the primary and secondary outcomes of patients with complicated acute pancreatitis (CAP) of moderate to severe intensity managed by using the hub-and-spoke model. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Surgery, North Cumbria Integrated Care, Carlisle, UK, from January 2014 to December 2018. METHODOLOGY: Retrospective analysis of 496 episodes of acute pancreatitis managed in 405 patients was done. Data for demographic features and clinical outcomes were analysed. In patients with recurrent admissions, only index admission was considered for analysis. Complicated acute pancreatitis was defined by using the revised Atlanta classification and included all the acute pancreatitis patients with local and or systemic complications.    Results: The frequency of CAP was 21.7% (88/405). The mean patients' age was 62.11 ± 17.90 years. The intensive therapy unit (ITU) admission rate was 33% (n = 29), whereas the overall intervention rate was 43.2% (n = 38). The in-hospital mortality rate was 10.2% (n = 9), and the overall mortality rate was 14.8% (n = 13). A comparative analysis of clinical outcomes according to the revised Atlanta classification showed that the rate of complications, need for ITU admission, duration of hospital stay, in-hospital mortality and overall mortality were significantly higher in patients with moderately severe AP (MSAP) and severe AP (SAP). CONCLUSION: The rate of progression from mild AP to MSAP and SAP remains high. Patients with CAP are at higher risk of ITU admission, prolonged hospital stay, in-hospital mortality and overall mortality. To improve clinical outcomes, the progression of AP to severer forms should be prevented by developing newer strategies, and in cases where complications have already developed, the mortality rate needs to be improved by developing innovative treatment modalities. KEY WORDS: Acute pancreatitis, Complicated acute pancreatitis, Revised Atlanta classification, Morbidity, Mortality, Survival analysis, Hub and spoke model.

C-Reactive Protein as a Predictor of Complicated Acute Pancreatitis: Reality or a Myth?

Introduction C-reactive protein (CRP) has been reported as a predictor of the severity of acute pancreatitis (AP). However, there is conflicting evidence in the literature. The proposed cut-off values and intervals for best prediction include an absolute value of 150 at 48 hours; an absolute value of 190 at 48 hours; and the interval change in CRP of 90 at 48 hours. The current study assesses the value of CRP at different intervals and cut-offs in predicting complicated acute pancreatitis (CAP) and compares its performance against other available predictors like neutrophil to lymphocyte ratio (NLR); Glasgow scoring system and modified CT severity index (MCTSI).  Methods Analysis of prospectively maintained data for index episodes of acute pancreatitis managed in 225 patients over a period of five years (2014-2018) was done. CAP was defined by using revised Atlanta classification and included all the AP patients with local and or systemic complications. It was used as a gold standard. Diagnostic and predictive performance of different biochemical markers and multifactorial scoring systems were determined by analyzing receiving operating curves (ROCs), the area under the curve (AUC), sensitivity, specificity, and predictive values (positive and negative).  Results Out of 225 patients, 122 were female while 103 patients were male. CAP developed in 47 patients (20.9%) while 178 (79.1%) patients had mild AP. Overall, in-hospital mortality rate was 1.8% (n=4). ROC analysis demonstrated that CRP at admission had low discriminatory value (AUC= 0.54, p-value=0.74). CRP at 48 hours had AUC of 0.70 (p-value=0.007). At a cut-off of 150, the positive predictive value (PPV) of 150 was 30 %. The PPV of CRP at 48 hours at a cut-off of 190 was 28%. Interval change in CRP at 48 hours greater than 90 had a PPV of 26 %. Further comparison of CRP with other scoring systems like Glasgow scoring system (AUC= 0.65), NL ratio (AUC=0.54), and MCTSI was performed. Among the single predictors, although, NL ratio showed good sensitivity at a cut-off value of 4.7 (87.23%), however, its discriminatory power was negligible (AUC=0.542, p-value=0.513). The overall best performance was achieved by the MCTSI scoring system at a cut-off of 3 (AUC=0.90, sensitivity=83.33 %, specificity=100%, diagnostic accuracy=94.49%).  Conclusion CRP measured at admission or at 48 hours has a very limited role in the prediction of CAP. Along with other scoring systems, its negative predictive value should be used to predict cases with mild AP which can help in clinical decision making for early discharge or management of such patients on ambulatory care basis. MCTSI scoring system can be used in cases with high suspicion of CAP.

Novel Use Of Age-Adjusted Charlson Comorbidity Index (ACCI) As A Risk Stratification Tool For Development Of Postoperative SARS-COV-2 Infection In Surgical Patients.

BACKGROUND: Current study documents the role of Age adjusted Charlson Comorbidity Index (ACCI) as a stratification tool for the development of postoperative SARS-CoV-2 infection in surgical patients. METHODS: This prospective cohort study was conducted over the period of 8 weeks starting on 1st of March 2020. Sampling was convenience and purposive and included all consecutive patients who underwent any surgical procedure. Follow up period was 30 days. Outcomes included postoperative SARS-CoV-2 infection, morbidity and 30-day mortality. Risk factors for development of infection were detected by univariate and multivariate analysis. RESULTS: Postoperative SARS-CoV-2 infection developed in 37 cases while 131cases remained confirmed negative. Of 37 patients, 18 were male while 19 were female. Postoperative complications developed in 17 patients (45.9%). In-hospital 30-day mortality was 16.2% (n=6). The factors that increased the chances of postoperative SARS-CoV-2 infection (p<0·00) included increasing age, higher ACCI Score, emergency surgery, trauma, orthopaedic and vascular procedures, spinal anaesthesia, and surgeries of complex nature. In adjusted analyses, predictors of postoperative infection included ACCI score of 4 or more (5.54 [1·51-20.34], p<0·01), and orthopaedics or vascular procedures versus others (12.32 [1.98-76.46], p<0·007). Based on infection rates across the different scores of ACCI, cohort was divided into 3 groups. ACCI score of zero had postoperative SARS-CoV-2 infection rate of 1.9 % (negative predictive value, 98.1%) compared with 36.26% in patients with score of 4 or more (sensitivity, 89.19%). CONCLUSIONS: Low risk surgical patients (ACCI=0) should have universal precautions, while intermediate risk group (ACCI=1- 3) should have extra precautions. The options for high-risk patients (ACCI ≥4) include cancellation of nonurgent surgery; delaying the surgery till optimization of modifiable factors; or reverse isolation/ shielding in perioperative period if surgery cannot be cancelled.

A Novel Dual-Phase Activation-Dependent Foot-Switch Mechanism for Surgical Energy Devices as an Asset in Early Surgical Training: A Proof of Concept Study.

Introduction. Many processes exist that limit or eliminate the incidence of adverse events in general surgery including the World Health Organization safety checklist. Technology and device advancement has a potentially expanding role in the context of surgical safety. Materials and Methods. A dual controlled accessory electrical diathermy footswitch (Permissive diathermy foot switch device or PDf) device concept was developed in an effort to improve patient safety in theatre and enhance opportunities in training. Electrical diathermy is only activated if the senior supervising surgeon and the novice surgeon simultaneously activate their interconnected footswitches. The activation of the PDf accessory footswitch device allows a senior surgeon to exert control on "initiation" of activation of diathermy devices operated by a novice surgeon (foot on pedal) as well as when desiring to deactivate the device (foot off pedal). Results. A process of designing and prototyping was initiated to define the purpose and the functionality of the PDf device up till the stage of a fully functioning prototype. The PDf device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was on a nonbiological model to determine efficacy and safety and passed its laboratory testing phase and was deemed ready for clinical use. Conclusion. We demonstrated the feasibility and functionality of the PDf device and propose a positive role in surgical training in the context of early surgical training and specific circumstances where more control is needed.

An overview of evidence-based management of hepatocellular carcinoma: a meta-analysis.

INTRODUCTION: An increasing trend of incidence in hepatocellular carcinoma (HCC) has been recorded in most developed countries. HCC ranks among the ten most common cancers worldwide. The health costs and burden to the economy implicated by HCC are huge. In recent years, the surveillance programs and screening for the disease, in addition to increasing awareness, led to the detection of smaller precursor lesions of HCC in the liver. The rise of molecular-targeted therapies and the publication of various conflicting guidelines on the management of the disease demand a review of evidence into the curative therapies and medical management of HCC. AIMS: The primary objective was to identify the survival benefit of the primary medical modalities in HCC, as more trials were uncovered between 2005 and 2010. The secondary objective was to conduct a meta-analysis. Selection criteria were implemented to select randomized controlled trials (RCTs), to include in this study. After selection, all the articles were ranked according to their strength. MATERIALS AND METHODS: The MEDLINE, CANCERLIT, Embase databases, and the Cochrane Library were reviewed using the national library of health website. The time limit used for searching for RCTs was between January 2005 and December 2010. Overall survival and the cumulative probability of no recurrence were the primary endpoints considered in the studies to be assessed. These endpoints were measured over one, two, or three years, depending on the size of the study and the length of follow-up. The software package comprehensive meta-analysis ver 2.0.exe (Biostat, USA) was used to comply with the results, to conduct the meta-analysis, and help with analyzing the data. RESULTS: The original general search yielded 193 RCTs between 2005 and 2010. Only 32 studies met the inclusion criteria. However, after the ranking of the studies according to strength, only 17 studies were eventually selected. The 17 studies were subsequently classified according to the following; surgical resection (n = 2); percutaneous treatments (n = 5); chemoembolization (n = 1); systemic treatments (n = 8); and other treatments (n = 1). Randomized studies comparing the percutaneous ethanol injection (PEI) to the surgical resection were inconclusive. However, percutaneous treatments showed results similar to surgical resection in terms of overall survival. The meta-analysis comparing PEI to radiofrequency ablation (RFA) showed RFA to be superior to PEI in terms of overall survival at three years (odds ratio 1.698; 95% CI 1.206 - 2.391; P = 0.002). When adverse events were considered there was no statistically significant difference between the RFA and PEI groups (odds ratio 1.199; 95% CI 0.571- 2.521; P = 0.632). CONCLUSION: RFA should be the first-line treatment in patients with a single small HCC tumor ≤ 3 cm. Careful patient selection is crucial prior to transarterial chemoembolization (TACE), as the procedure may be associated with an increased risk of liver failure. Tamoxifen has no role to play in the treatment of HCC. Sorafenib should be the first-line treatment in patients with advanced and inoperable HCC. The role of Sorafenib in the management of early stage HCC remains to be determined.

Liver resection with bipolar radiofrequency device: Habib 4X.

BACKGROUND: Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib 4X, a new bipolar RF device designed specifically for liver resection is described here. METHODS: Habib 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak. RESULTS: Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringle's manoeuvre). Mean intraoperative blood loss was 305 ml (range 0-4300) ml, with less than 5% (n=18) rate of transfusion. CONCLUSION: Habib 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.

Justifying a third pancreas transplant: a case report.

Early pancreas graft failure after simultaneous pancreas-kidney transplant can occur in up to 20% of recipients. Results after pancreas retransplant continue to improve, with results comparable to primary pancreas transplants. We describe an unusual case of a third pancreas transplant in which a remnant of a previous arterial Y-graft was used for the arterial anastomosis, and we discuss the factors used to justify the decision to do a third pancreas transplant.

Results of major hepatectomy without vascular clamping using radiofrequency-assisted technique compared with total vascular exclusion.

BACKGROUND/AIMS: To improve major hepatectomy results, various techniques with or without vascular clamping have been developed. We report the results of major hepatectomies performed with radiofrequency-assisted technique (RF) without vascular clamping and compare these results to total vascular exclusion (TVE). METHODOLOGY: All patients who underwent a major hepatectomy between 1994 and 2004 were identified. Outcome of liver resection with these two techniques was compared. Data including blood transfusion requirement, intensive care admission, postoperative liver function, morbidity and mortality were collected. RESULTS: Seventy-eight patients underwent a major hepatectomy including resection using TVE (n = 51) and RF (n = 27). Blood transfusion rate was lower in RF group (26% vs. 53%, P = 0.04). Postoperative morbidity rate was similar in both groups, but there was a reduction in postoperative liver failure in RF group (0 vs. 9, p = 0.05). One patient developed biliary leak postoperatively in the RF group. No patients developed postoperative hemorrhage. In RF group, there was a reduction in both ICU admission (6% vs. 92%, P < 0.0001) and postoperative stay (10 vs. 17 days, P < 0.004). A substantial saving of pound 5185 per-patient could be achieved in RF patients. CONCLUSIONS: Major hepatectomy using RF decreases the rates of blood transfusion, postoperative liver failure, ICU admission, postoperative stay and the price, when compared to TVE.

Concordant F-18 FDG PET and Y-90 Bremsstrahlung scans depict selective delivery of Y-90-microspheres to liver tumors: confirmation with histopathology.

Selective Internal Radiation Therapy using yttrium-90 (Y-90) microspheres is a novel method for the treatment of advanced liver cancer. The procedure involves intrahepatic arterial delivery of the Y-90 microspheres. Since hepatic tumors derive their blood supply mainly from the hepatic arteries, it is assumed that the microspheres will be preferentially delivered to tumor cells. However, this has not been confirmed at histology. We report a case of hepatic metastasis from an unknown primary, where treatment with Y-90 microspheres was the only available option due to inoperability and low tolerance to chemotherapy. Pretherapy F-18 FDG-PET scan defined the distribution of the active tumor within the liver. Following the injection of Y-90 microspheres, Bremsstrahlung imaging showed uptake only in the F-18 FDG-PET-defined tumor area. Post therapy debulking surgery was performed and histopathology of tumor samples confirmed the preferential distribution of the injected microspheres in the hepatic tumor circulation with very little in the healthy liver tissue. The case confirms the preferential blood flow to hepatic tumors as depicted by the distribution of Y-90 microspheres injected directly in the hepatic arteries. It also demonstrates that concordance between F-18 FDG-PET and Y-90 Bremsstrahlung scans can be a useful clue to the in vivo distribution of microspheres.

Assessment of response to treatment of unresectable liver tumours with 90Y microspheres: value of FDG PET versus computed tomography.

INTRODUCTION: Selective internal radiation therapy (SIRT) with SIR spheres (90Y microspheres) is a treatment option for liver tumours in patients in whom other therapies are inappropriate or have failed. This study aims to assess the value of FDG PET in assessing the response to SIRT as compared to computed tomography (CT). MATERIAL AND METHODS: Twenty-one patients (11 F, 10 M; age range 40-75 years, mean, 58 years) received SIR spheres at the Hammersmith Hospital. One patient received two treatments. Most patients had colorectal metastases (n=10), while the others (n=11) had liver metastasis from different primaries. The mean administered dose was 1.9 GBq (range, 1.2-2.5 GBq). Follow-up was done with FDG PET and CT at 6 weeks, and 6-monthly thereafter. Pre-therapy and post-therapy CT and PET scans were assessed visually (RECIST criteria for CT) and semi-quantitative for PET using the standardized uptake value (SUV). RESULT: Eighty-six percent of patients showed decreased PET activity at 6 weeks while only 13% showed a partial response in the size of tumour on CT scan. The mean pre-treatment SUV was 12.2+/-3.7 and the mean post-treatment SUV was 9.3+/-3.7 (P=0.01). CT imaging showed progressive disease in 27% patients and stable liver disease in 60% patients. Based on FDG PET results one patient had surgery for down-staged tumour. CONCLUSION: FDG PET imaging is more sensitive than CT in the assessment of early response to SIR spheres, allowing clinicians to proceed with further therapeutic options.

Management and prevention of adverse effects related to treatment of liver tumours with 90Y microspheres.

BACKGROUND AND AIM: Selective internal radiation therapy with 90Y microspheres (SIR spheres) is increasingly used in the treatment of extensive liver tumours. Careful selection and preparation of patients are necessary to avoid possible adverse effects. We aimed to evaluate the incidence and severity of adverse effects resulting from the administration of SIR spheres during therapy. MATERIALS AND METHODS: Between June 2004 and August 2006, 21 patients (11 women and 10 men; age range 40-75 years; mean, 58 years) with a wide range of extensive liver tumours were treated with SIR spheres. The mean administered dose was 1.87 GBq (range 1.2-2.5 GBq). During the follow-up period of 26 months, all adverse effects were monitored and classified according to the National Cancer Institute criteria. RESULTS: Four patients had adverse effects: one case of cholecystitis followed by fibrosis and portal hypertension, one case of peptic ulceration and two cases of radiation hepatitis. All cases responded to appropriate therapy. CONCLUSION: Proper selection of patients and accurate interpretation of pre-treatment investigations are vital for minimizing adverse effects following therapy with SIR spheres. In our experience, all adverse effects were moderate with no life-threatening consequences.

Experience with hystidine tryptophan ketoglutarate versus University Wisconsin preservation solutions in transplantation.

We present our experience with histidine tryptophan ketoglutarate (HTK) and University Wisconsin (UW) preservation solutions in liver transplantation and a review of the literature in pancreas and kidney transplantation comparing these solutions. A group of 134 liver transplantations in 123 recipients was analyzed retrospectively. Grafts procured in adults were perfused with HTK in 63 cases and with UW in 71 cases. We compared results according to preoperative, intraoperative, and postoperative parameters, as well as complications and survival. No differences regarding donor and recipient data, intraoperative fresh frozen plasma (FFP) substitution, length of intensive care unit (ICU) stay, and ischemic damage of the graft were found. The rate of complications was comparable in both groups. However, the bilirubin was higher in the UW group. The rate of biliary complications was higher in the UW group (n = 8) versus the HTK group (n = 5). HTK ischemic type biliary lesions (ITBL) were only present in the UW group. Patient and graft survival were statistically nonsignificant. The data confirm that HTK and UW, with exception of biliary complications, are considered comparable in clinical liver transplantation. The same conclusion can be taken from the literature analyzed concerning renal transplantation, and in smaller groups of pancreas transplants, similar results were published.

Tuberculosis anorrectal / Anorectal tuberculosis

Se presentan dos casos de T.B.C. anorrectal estudiados y tratados en el Servicio de Cirugía del H.A.C., uno con úlcera perianal y otro con fístula anal, con estudio anatomopatológico compatible con T.B.C., comprobándose T.B.C. pulmonar activa mediante Rx. de tórax, baciloscopia y R. de Mantoux. Se realiza en el primer caso tratamiento específico con isoniacida y rifampicina y estreptomicina, al segundo caso se lo interviene, quirúrgicamente y luego se inicia la quimioterapia con las mismas drogas que al anterior. La curación es en forma completa a los 15 días en el primer caso y a los 30 en el segundo

Tuberculosis anorrectal / Anorectal tuberculosis

Se presentan dos casos de T.B.C. anorrectal estudiados y tratados en el Servicio de Cirugía del H.A.C., uno con úlcera perianal y otro con fístula anal, con estudio anatomopatológico compatible con T.B.C., comprobándose T.B.C. pulmonar activa mediante Rx. de tórax, baciloscopia y R. de Mantoux. Se realiza en el primer caso tratamiento específico con isoniacida y rifampicina y estreptomicina, al segundo caso se lo interviene, quirúrgicamente y luego se inicia la quimioterapia con las mismas drogas que al anterior. La curación es en forma completa a los 15 días en el primer caso y a los 30 en el segundo (AU)