The use of Seamguard to buttress the suture repair of a staple line leak following laparoscopic gastric bypass for obesity.

Anastomotic and staple line leak following laparoscopic gastric bypass are recognised complications with significant mortality and morbidity. Several techniques have been described to reduce the incidence of staple line leaks, including reinforcement of staple lines using omental wraps, fibrin glue, and Peristrips and Seamguard. Using a similar principle, we describe a case report of the successful use of a Seamguard buttress in the repair of a staple line leak at the proximal gastric pouch following laparoscopic gastric bypass. The repair of the leak was confirmed by gastrogaffin contrast study as well as clinically as the patient progressed well in the postoperative period. Ten months following surgery, her weight had reduced from 125 kg (BMI 47.6 kg/m(2)) to 82.4 kg (BMI of 31.4 kg/m(2)). We suggest that surgeons facing similar problems may choose to employ this novel technique.

Risk assessment for severe postoperative hypocalcaemia after neck exploration for primary hyperparathyroidism.

BACKGROUND AND AIMS: A further development of the risk profile for severe postoperative hypocalcaemia after surgery for primary hyperparathyroidism (pHPT) was made with the aim of expanding the group of patients who can be discharged safely after 23 hours. METHODS: Prospective study with 156 consecutive pHPT patients (158 operations) during 2001 and 2002. Risk factors for postoperative severe hypocalcaemia (ionised calcium < 1 mmol/L), were (1) preoperative concentration of parathyroid hormone (PTH) > 35 pmol/L (five times the upper reference value, reference range 1.1 to 6.9), (2) history of previous neck surgery, (3) biopsy/excision of > 2 parathyroid glands or (4) concomitant thyroid surgery. RESULTS: The risk factors showed a sensitivity of 100 % (9/9). In 110 of the operations (70%) no risk factors were identified. Postoperative calcium levels were significantly lower after 48 operations with risk factor(s) identified, as compared to the group without risk factors (p < 0.01). Seven of 17 patients (41%) with PTH > 35 pmol/L developed severe postoperative hypocalcaemia. Two of 31 patients (6%) with PTH < 35 pmol/L in the presence of other risk factor(s) developed severe postoperative hypocalcaemia. CONCLUSION: Patients with no risk factor can safely been discharged from hospital on the first postoperative day. Patients with preoperative concentration of PTH > 35 pmol/ L (five times the upper reference value) should stay in hospital until nadir level of calcium is reached. Patients with concentration of parathyroid hormone less than 35 pmol/ L in the presence of other risk factor(s) may have an early discharge from hospital (second postoperative day) combined with outpatient measurements of calcium levels.

Aciclovir or ganciclovir universal prophylaxis of cytomegalovirus infection in liver transplantation: an economic analysis.

BACKGROUND: Cytomegalovirus (CMV) following orthotopic liver transplantation can result in significant morbidity and mortality. Prophylaxis with oral aciclovir (ACV) or ganciclovir (GCV) for all transplant recipients (universal prophylaxis) may be beneficial, but which agent is more cost-effective is unknown. METHODS: A single centre, retrospective study of all patients who had OLT at the Western Australian Liver Transplantation Service was performed. Patients received ACV from 1992 to 1998, and GCV from 1999 to 2001. A comparative cost-effectiveness analysis for the two groups was performed based on the mean total cost of the number of cases of CMV infection and disease as the clinical end-point. RESULTS: The ACV group comprised of 55 patients and there were 24 in the GCV group. The incidence of CMV disease was 7% and 4% for the ACV and GCV groups, respectively (P > 0.05). For CMV infection it was 16% and 8%, respectively (P > 0.05). GCV prevented more cases of CMV infection and disease than ACV but at an incremental cost of dollars A20,000 (dollars US10,172) per case prevented. Overall, ACV was more cost-effective than GCV by dollars A2200 (dollars US1119) per person. The cost benefit of ACV was derived principally through a reduced pharmaceutical cost. Both agents were well tolerated without development of antiviral resistance. CONCLUSIONS: Universal prophylaxis of CMV infection-following liver transplantation with aciclovir is more cost-effective than with ganciclovir.

Adult-to-adult living donor liver transplantation for fulminant hepatic failure.

The outcome of fulminant hepatic failure without timely liver transplantation is poor. We describe a 19-year-old woman with fulminant hepatic failure due to acute hepatitis B infection who received a living donor liver transplant from her sister. The donor's recovery was uneventful, allowing hospital discharge on Day 6. Two months after transplantation the recipient developed a biliary stricture requiring surgery. One year after transplantation, her liver function was normal.

Costs of accessing surgical specialists by rural and remote residents.

INTRODUCTION: Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting. METHODS: A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non-clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan-based service. RESULTS: An estimated saving of AU$1,077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time. CONCLUSION: The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available.

Failure of the Hong Kong criteria to predict the severity of acute pancreatitis.

CONCLUSION: The results of the present study demonstrate that the HK criteria do not provide effective prediction of severity. BACKGROUND: Fan et al. (1) have reported previously that a blood urea (BU) > 7.4 mmol/L and/or glucose (BG) > 11 mmol/L at the time of admission to hospital detects a severe attack of acute pancreatitis with a sensitivity of 76% and specificity of 75%. However, a similar study conducted in the West of Scotland did not confirm these findings (sensitivity 33% and specificity 83%). The reason underlying this discrepancy in prediction is unclear, but it may be because of differences in the nature of acute pancreatitis between Asian and Western populations. AIMS: In this study we examined the predictive ability of the Hong Kong (HK) criteria in a patient population similar to that studied by Fan et al. PATIENTS AND METHODS: A consecutive series of 130 patients experienced 135 attacks of acute pancreatitis. One-hundred-and-four (77%) attacks were mild and 31 (23%) severe (including 12 [9.0%] deaths). Eighty-nine (66%) episodes had a biliary etiology. In 19 (14%) of these episodes, the gallstones had a primary ductal origin being associated with recurrent pyogenic cholangitis. RESULTS: Median admission BU concentrations were 5.2 mmol/L (range 3.6-32.1 mmol/L) for the mild group and 7.6 mmol/L (range 3.6-28.8 mmol/L) for the severe group. Corresponding values of BG were 7.1 mmol/L (range 2.1-17.9 mmol/L) and 8.4 mmol/L (range 3.6-28.8 mmol/L), respectively. Differences in admission BU concentrations between patients with mild and severe episodes were significant (p = 0.0001). However, differences in BG concentrations were not (p = 0.16). In the severe group, 14 patients had BU and four patients BG concentrations above the cut-off values. The HK criteria predicted severe acute pancreatitis with a sensitivity of 52% and specificity of 80%. These results compare with values of 79 and 56% for the Ranson criteria and 83 and 60% for the Glasgow score. The best prediction was provided by the APACHE II score 24 h post admission (sensitivity 79%, specificity 82%).

The relationship between pancreatic enzyme release and activation and the acute-phase protein response in patients with acute pancreatitis.

It has been suggested that the severity of an attack of acute pancreatitis is related to the presence of intraglandular trypsinogen activation and that disease severity is also reflected by the degree of the acute-phase protein response. In this study we examine the relationships among amylase release, the degree of trypsinogen and prophospholipase A2 activation [as measured by urinary trypsinogen activation peptide (TAP) and prophospholipase A2 activation peptide (PLAP) concentrations], and the serum concentrations of the acute phase-protein C-reactive protein (CRP) and the principal mediator of the acute-phase protein response, interleukin-6 (IL-6). Twenty-four patients (14 mild and 10 severe attacks) were studied. Peak serum amylase concentrations were seen within 12 h and peak urinary TAP/creatinine (Cr) and PLAP/Cr ratios between 12 and 24 h after the onset of symptoms, preceding those of IL-6 and CRP. The integrated TAP/Cr and PLAP/Cr responses were significantly greater in those with severe disease [95% confidence internal (CI) = 106-259.6 pmol/mmol/h, p < 0.0008; and 95.1% CI = 462.2-3887 pmol/mmol/h, p < 0.003, respectively]. The integrated amylase response was not significantly greater in those with severe disease (95.6% CI = -415 to 832 IU/L/h, p < 0.14). There was a strong correlation among the integrated IL-6, TAP/Cr (r = 0.63, p < 0.01), and PLAP/Cr (r = 0.64, p < 0.01) responses but a poor correlation with the integrated amylase response (r = 0.19, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Trypsinogen activation peptides (TAP) concentrations in the peritoneal fluid of patients with acute pancreatitis and their relation to the presence of histologically confirmed pancreatic necrosis.

This study measured the volume and colour, as well as concentrations of trypsinogen activation peptides (TAP) in the peritoneal fluid of 22 patients with acute pancreatitis and related these findings to the presence of pancreatic necrosis. Nine patients had a severe attack with histologically confirmed pancreatic necrosis, seven a severe attack without confirmed necrosis, and six a mild attack, also without confirmed necrosis. A free fluid volume > 20 ml or free fluid colour > grade 5 on the Leeds chart, or both detected histologically confirmed pancreatic necrosis with a sensitivity of 100% and specificity of 31%. A total peritoneal fluid TAP concentration of > or = nmol detected histologically confirmed pancreatic necrosis with a sensitivity of 89% and specificity of 85%, figures comparable with contrast enhanced computed tomography. These findings suggest that the measurement of peritoneal fluid TAP concentrations can detect effectively histologically confirmed pancreatic necrosis and that such measurements may prove useful in the selection of patients for surgery.

The Hong Kong criteria and severity prediction in acute pancreatitis.

Fan et al. have reported that a blood urea > 7.4 mmol/L and/or glucose > 11 mmol/L at the time of admission to hospital detect severe acute pancreatitis with a sensitivity of 76% and specificity of 80.3%. We have retrospectively applied these criteria to a consecutive series of 125 patients with a diagnosis of acute pancreatitis within the West of Scotland. Utilizing the Hong Kong criteria we were only able to detect severe attacks of acute pancreatitis with a sensitivity of 33% (specificity of 83%). By lowering the concentration of urea and glucose employed to > or = 4.9 mmol/L and > or = 7.5 mmol/L, respectively, and utilizing peak concentrations recorded during the first 48 h rather than values measured at the time of admission, we were able to increase the sensitivity to 65% while reducing the specificity to 77%. Even after modification, the Hong Kong criteria were a less effective means of identifying severe attacks of acute pancreatitis than either the Glasgow scoring system (sensitivity 78% and specificity 86%) or clinical assessment at 48 h (sensitivity 82% and specificity 96%).

Role of interleukin-6 in mediating the acute phase protein response and potential as an early means of severity assessment in acute pancreatitis.

A number of laboratory and clinical studies have shown that interleukin-6 is the principal mediator of the acute phase protein response. In this study the relationship between serum concentrations of interleukin-6 and C-reactive protein in acute pancreatitis are examined and the ability of interleukin-6 to discriminate between severe and mild attacks is assessed. We have studied 24 patients (10 severe and 14 mild). Serum samples were collected on admission, six hourly for 48 hours and then 12 hourly for a further three days. When the areas under the curves of individual patients were compared there was a strong correlation between the total production of interleukin-6 and C-reactive protein (r = 0.73) (Spearman rank correlation) and peak interleukin-6 and C-reactive protein concentrations (r = 0.75), suggesting a close relationship between interleukin-6 and C-reactive protein production. Both on admission and peak interleukin-6 concentrations were significantly higher in patients with severe than mild disease. There was no significant difference in on admission C-reactive protein concentrations, although significant differences were seen when peak concentrations were considered. Utilising a peak interleukin-6 concentration of > 130 u/ml, we were able to distinguish between severe and mild attacks of acute pancreatitis with a sensitivity of 100% and specificity of 71%. These figures were comparable with those for peak C-reactive protein, a C-reactive protein of > 150 mg/l detecting severe attacks of acute pancreatitis with a sensitivity of 90% and specificity of 79%. In view of the fact that interleukin-6 concentrations peaked earlier than those of C-reactive protein, interleukin-6 is capable of providing comparable, but earlier severity prediction than C-reactive protein.

Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems.

The APACHE II severity of disease classification system has been examined prospectively in 160 patients with acute pancreatitis. Using clinical and simple laboratory data APACHE II was able to provide useful discrimination between uncomplicated, complicated and fatal attacks within a few hours of admission. Peak APACHE II scores (recorded during the first 3 days) had a prognostic accuracy similar to the multiple factor scoring systems, but then incurred a similar delay. Patients could be graded according to their risk of death or of developing a major complication; no deaths occurred in patients with a peak APACHE II score less than 10. APACHE II can be repeated daily, uncomplicated attacks demonstrating falling scores in association with clinical improvement, in contrast to the rising scores associated with clinical deterioration in those dying early. APACHE II appears to reflect any continuing disease activity and may prove a useful means of monitoring the course of the illness and response to therapy.

Trypsinogen activation peptides assay in the early prediction of severity of acute pancreatitis.

Trypsinogen activation can be quantified by measurement of released activation peptides (TAP assay). TAP assay in urine was performed on admission for 55 patients with acute pancreatitis. TAP concentration correlated with subsequent disease severity in 87%, whereas C-reactive protein concentration, and multifactorial scoring at 48 h, were correct in 55% and 84%. Sensitivity and specificity for TAP assay were 80% and 90%, for C-reactive protein 53% and 55%, and for multifactorial scoring at 48 h, 60% and 93%. Urine TAP assay distinguishes acute pancreatitis without trypsinogen activation from acute pancreatitis with trypsinogen activation, and helps to identify patients who will progress to the severe acute disease. Use of the assay should allow early intensive treatment of those who need it.

Primary malignant melanoma of the gall bladder.

A case of primary malignant melanoma of the gall bladder is reported, in which a 29 year old man presented with acute cholecystitis which led to perforation of the gall bladder and biliary peritonitis. To help in the differentiation between primary and secondary malignant melanoma in the gall bladder and to overcome some of the difficulties posed by the clinical identification of what is often a small or relatively inaccessible primary tumour, it is suggested that certain criteria should be fulfilled before primary melanoma is diagnosed. (i) Tumours must be solitary and arise from the mucosal surface of the gall bladder; (ii) they must either be papillary or polypoid; (iii) they must either display junctional activity or have any other primary sites excluded by history taking, examination, and investigation. If these criteria are applied to the published case reports of primary malignant melanoma, only six cases, including the present one, can be regarded as true primary tumours.