Beyond the revised atlanta classification: a comprehensive review of the imaging assessment of acute pancreatitis and its complications.

While the Revised Atlanta Classification outlines the primary complications of acute pancreatitis, it is crucial to recognize additional factors that contribute to morbidity and mortality associated with acute pancreatitis. In this review, we discuss the imaging-based classification and staging of acute pancreatitis as described by the Revised Atlanta Classification, but also provide a comprehensive understanding of the pancreatic anatomy and its relation to surrounding structures, which is essential for imaging-based assessment of both acute pancreatitis and its complications. We further extend the discussion beyond common complications such as pseudocysts and walled-off necrosis to include lesser-known but significant complications such as peripancreatic infection, disconnected ductal disconnection syndrome, thrombosis, hemorrhage, and gastrointestinal complications. Additionally, illustrative examples are presented to highlight relevant points pertaining to real-life imaging assessment of acute pancreatitis and its complications.

Cross-sectional imaging of pancreatic leak: a pictorial review.

Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the abdominal cavity. While often associated with pancreatic surgical procedures, trauma and necrotizing pancreatitis are also common culprits. Cross-sectional imaging, particularly computed tomography, plays a crucial role in assessing postoperative conditions and identifying both early and late complications, including pancreatic leaks. The presence of fluid accumulation or hemorrhage near an anastomotic site strongly indicates a pancreatic fistula, particularly if the fluid is connected to the pancreatic duct or anastomotic suture line. Pancreatic fistulas are a type of pancreatic leak that carries a high morbidity rate. Early diagnosis and assessment of pancreatic leaks require vigilance and an understanding of its imaging hallmarks to facilitate prompt treatment and improve patient outcomes. Radiologists must maintain vigilance and understand the imaging patterns of pancreatic leaks to enhance diagnostic accuracy. Ongoing improvements in surgical techniques and diagnostic approaches are promising for minimizing the prevalence and adverse effects of pancreatic fistulas. In this pictorial review, our aim is to facilitate for radiologists the comprehension of pancreatic leaks and their essential imaging patterns.

Anesthesia preoperative evaluation clinic (APEC) restructuring plan for improving the quality of surgical patient flow

Introduction: Anesthesia preoperative evaluation clinics (APECs) are useful for high-risk surgical patient care, as they improve perioperative outcomes and optimize patient care flow. At Hospital de Clínicas de Porto Alegre, APEC assesses 20% of all patients undergoing surgery, showing the importance of implementing strategies to improve outpatient clinic efficiency by prioritizing high-risk patients. Methods: Using a specific quality management tool for process improvement (PDCA, which stands for Plan/Do/Check/Act), new protocols were developed for patient referral and preoperative evaluation. Clinical staff was trained in the new routines, and an electronic screening system for patient referral was adopted. Data on patient profiles, referring surgical specialties, type of surgery, and waiting times for appointment and surgical procedure were compared before and after the intervention. Results: APEC performed 1,286 appointments between 2013 and 2016, including 733 pre-intervention and 553 post-intervention. There was a significant decrease in the appointments for patients undergoing minor surgery and an increase in the appointments for those undergoing major surgery. The waiting time between referral to APEC and first APEC appointment reduced from 46 to 16 days. In addition, there was an increase in vascular, orthopedic, and urology referrals, as well as a reduction in ophthalmology and general surgery referrals. Conclusions: The PDCA method assisted with conceiving, executing, and monitoring the implemented strategies for changing the profile of patients evaluated at APEC. The major challenge is to measure the long-term impact of this intervention and expand care through specific strategies for surgical specialties and procedures.(AU)

Comparison of clinical outcomes in patients undergoing mitral valve replacement with mechanical or biological substitutes: a 20 years cohort.

BACKGROUND: The choice of prosthesis for mitral valve replacement still remains controversial. This study assessed mortality, bleeding events and reoperation in patients who underwent mitral valve replacement surgery with biological or mechanical substitutes. METHODS: A total of 352 patients who underwent mitral valve replacement surgery between 1990 and 2008 with 5 to 23 years of follow-up were retrospectively evaluated in a cohort study. RESULTS: The 5, 10, 15 and 20 year survival rates after surgery using a mechanical substitute were 87.7%, 74.2%, 69.3% and 69.3%, respectively, while after surgery with a biological substitute, they were 87.6%, 71.0%, 64.2% and 56.6%, respectively. There was no significant difference between the two groups (p = 0.38). In the multivariate analysis, the factors associated with death were age, bleeding events and renal failure. The probabilities of remaining free of reoperation at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 94.4%, 92.7%, 92.7% and 92.7%; after surgery with a bioprosthesis, they were 95.9%, 86.4%, 81.2% and 76.5%, respectively (p = 0.073). There was a significantly higher incidence of reoperation for the bioprosthetic valve replacement group (p = 0.008). The probabilities of remaining free of bleeding events at 5, 10, 15 and 20 years after surgery using a mechanical substitute were 95.0%, 91.0%, 89.6% and 89.6%, respectively, while after surgery with a bioprosthesis, they were 96.9%, 94.0%, 94.0% and 94.0%, (p = 0.267). CONCLUSIONS: The authors concluded that: 1) mortality during follow-up was statistically similar for both groups; 2) there was a greater tendency to reoperation in the bioprosthesis group; 3) the probability of remaining free from reoperation remained unchanged after 10 years' follow-up for patients with mechanical substitute valves; 4) the probability of remaining fee from bleeding events remained unchanged after 10 years' follow-up for patients given bioprostheses; 5) the baseline characteristics of patients were the greatest determinants of later mortality after surgery; 6) the type of prosthesis was not an independent predictive factor of any of the outcomes tested in the multivariate analysis.