Transitioning to a high volume centre for Whipple pancreaticoduodenectomy in Western Australia: a single centre experience.

BACKGROUND: Pancreaticoduodenectomy (PD) is a curative resection for peri-ampullary tumours associated with high rates of peri-operative mortality and morbidity. The global trend is towards the establishment of high volume centres to reduce this. Australia faces geographical and population distribution challenges. Western Australia has centralized PD to two centres and we present the results of our institution in transitioning to a high volume centre. METHODS: This was a prospective database of all PDs performed at our institution from 1 January 2005 to 2 April 2020. Mortality outcomes included peri-operative, 30 day and 90 day mortality. Complications, readmission and reinterventions at 90 days were recorded. The annual volume exceeded 20 from 2015. Outcomes prior to this were compared to characterize the transition to a high volume centre. RESULTS: One hundred and twenty eight PDs were performed in Period 1 (1 January 2005-31 December 2014) and 170 in the high volume Period 2 (1 January 2015-2 April 2020). There was a non-statistically significant reduction in 90 day mortality in Period 2 (4.69% versus 1.18%, p = 0.06). There was a reduction in clinically significant post-operative pancreatic fistulas (31.25% versus 11.76%, p < 0.05), delayed gastric emptying (39.84% versus 22.35%, p < 0.05) and transfusion requirements (56.25% versus 17.65%, p < 0.05). Severe complications (Clavien-Dindo III or greater) were reduced (30.47% versus 18.24%, p < 0.05). CONCLUSION: Since establishing a high volume service, there was a reduction in post-operative complications and 90 day mortality. This is in line with outcomes from international centres and demonstrates the improvements that can be made.

Jejunal rupture resulting from a collision in soccer.

Small bowel rupture in blunt force trauma usually results from high-velocity and high-energy forces. The occurrence of this following collision in sport is a rare event that requires urgent surgical intervention. This is the case of a 27-year-old male who sustained a jejunal rupture following a collision during a game of soccer.

Atraumatic splenic rupture in a patient treated with apixaban: A case report.

INTRODUCTION: Splenic rupture is often seen in the context of significant trauma. Atraumatic ruptures are described in the context of malignancy, inflammation or infection directly affecting the spleen. Splenic ruptures occurring in patients taking apixaban, a factor Xa inhibitor, are challenging due to the scarcity of a direct reversal agent. PRESENTATION OF CASE: A 66 year old male presented with syncope and back pain and was found to be haemodynamically unstable and tender in the left upper quadrant. There was no preceding trauma. He has a background of extensive major arterial reconstruction and was taking apixaban for atrial fibrillation. A diagnosis of splenic rupture was confirmed on cross sectional imaging. A laparotomy and splenectomy was necessitated as salvage therapy following splenic artery embolisation. He recovered well and was discharged home 6 days after laparotomy. CONCLUSION: Definitive intervention is required for the management of splenic ruptures. A high level of clinical suspicion should be maintained in patients taking direct oral anticoagulants presenting with haemodynamic instability. Open splenectomy remains the most definitive option for treatment of atraumatic rupture in anticoagulated patients.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures.

INTRODUCTION: There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB. METHODS: A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors. RESULTS: A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements. CONCLUSION: This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.