Pancreaticoduodenectomy for distal cholangiocarcinoma at a South African centre.

BACKGROUND: Surgical resection of distal cholangiocarcinoma (dCCA) offers the only chance for cure and long-term survival. The current literature provides limited data regarding the surgical management and long-term outcomes of dCCA. This study aims to describe the presentation, management, and outcomes of dCCA at a large academic referral centre in South Africa. METHODS: A retrospective study was performed of all patients who underwent curative-intended surgery for dCCA at Groote Schuur Hospital from 2000 to 2020. RESULTS: Over 21 years, 25 patients underwent pancreaticoduodenectomy (PD) for dCCA. Most patients were male (68%), and the mean age was 56.8 years. Of the patients, 22 (84%) underwent preoperative biliary drainage (PBD). There were 29 recorded complications in 25 patients; postoperative pancreatic fistula (POPF) and surgical site infection (SSI) each occurred in 24% of the cohort. The mean hospital stay was 17.2 days without perioperative mortality. With none lost to follow-up, the 1, 3, 5, 10, and 20-year survival rates were 84%, 24%, 16%, 12%, and 4%, respectively. Only T3 status was associated with significantly lower overall survival (OS). Age, albumin levels, PBD, margin status (R0 vs. R1), and nodal status (N0 vs. N1/N2) did not influence OS. CONCLUSION: This is the first study detailing the management and outcomes of dCCA from sub-Saharan Africa (SSA). Despite the complete resection of dCCA, the prognosis is poor, and the long-term survival rate in our study is equivalent to that reported in the literature. T3 disease is an important prognostic factor and is associated with poor OS. Surprisingly, nodal disease and margin status did not affect OS in the cohort of patients.

Liver resection for hepatocellular and fibrolamellar carcinoma in a South African tertiary referral centre - an observational cohort analysis.

BACKGROUND: More than 80% of global hepatocellular carcinomas (HCC) occur in sub-Saharan Africa (SSA) and South- East Asia. Compared with the rest of the world, HCC in SSA has the lowest resection and survival rates. This study assessed outcome following liver resection for HCC and fibrolamellar carcinoma (FLC) at a tertiary referral centre in South Africa. METHODS: A retrospective analysis was done of all liver resections for HCC and FLC at Groote Schuur Hospital and the University of Cape Town Private Academic Hospital between January 1990 and December 2021. Three groups were compared, (i) HCC occurring in normal livers, (ii) HCC occurring in cirrhotic livers, and (iii) fibrolamellar carcinoma. Postoperative complications were classified as per the expanded accordion severity grading system. Median overall survival (OS) and 95% confidence intervals (CI) were calculated. RESULTS: Forty-eight patients were included in the study, 25 for HCC in non-cirrhotic livers, 15 in cirrhotic livers and eight for FLC. Thirty-six patients (75%) underwent a major resection. No mortality occurred but 16 patients (33%) developed grade 1 to 4 complications postoperatively. Thirty-three patients (69%) developed recurrence of HCC following their initial resection of whom 29 (60%) ultimately died. Median overall survival (OS) for the total cohort after surgery was 57.2 months, 95% CI (29.7-84.6), 64.2 months (29.7-84.6), 61.9 months (28.1-95.6), and 31.7 months (1.5-61.8) for patients with HCC in non-cirrhotic livers, FLC and HCC in cirrhotic livers respectively. CONCLUSION: Liver resection for HCC and FLC was safe with no mortality, but one-third of patients had associated postoperative morbidity. The high long-term recurrence rate remains a major obstacle in achieving better survival results after resection.

The role of endoscopic retrograde cholangiopancreatography in the treatment of hepatic cystic Echinococcus in a high HIV prevalence population: a retrospective cohort study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a useful, minimally invasive intervention in managing complicated hepatic cystic echinococcosis (HCE). This study aims to assess the use of ERCP in a South African HCE cohort with and without human immunodeficiency virus (HIV) co-infection. METHODS: An analysis was performed of patients with HCE who were assessed for surgery and underwent ERCP at a tertiary hospital in South Africa between 2011 and 2023. Demographics, clinical data, imaging characteristics, operative management, and postoperative complications were compared between HIV-negative (HIV-) and HIV-positive (HIV+) cohorts. RESULTS: Of the 91 patients assessed, 45 (mean age 34.6 years, 73.3% females, 23 HIV+) required ERCP. HIV status did not significantly affect cyst characteristics or surgical outcomes. HIV+ patients had a higher incidence of intraoperative bile leaks (p = 0.025). There were 18 patients who underwent preoperative ERCPs, mainly for biliary-cyst complications primarily causing obstructive jaundice. A total of 40 patients required postoperative ERCPs, mainly for bile leaks. There were no ERCP-related mortalities and only one case of pancreatitis. ERCP success rates were comparable in both cohorts, with an overall success rate of 86.7%. CONCLUSION: HIV co-infection did not significantly impact the clinical course or outcomes of cystic echinococcosis (CE) patients undergoing ERCP. Perioperative ERCP proved effective in managing biliary complications of HCE as well as postoperative complications, regardless of HIV status. This study underscores the importance of endoscopic interventions in the comprehensive management of CE.

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding.

BACKGROUND: This study investigated the value of prognostic scores to predict 90-day, 1-, 3- and 5-year survival after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding who failed endoscopic intervention. METHODS: The Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease Sodium (MELDNa), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Child-Pugh (C-P) grades and scores were calculated using Kaplan-Meier curves and Cox proportional hazards models in sTIPS patients treated between August 1991 and November 2020. RESULTS: Thirty-four patients (29 men, 5 women), mean age 52 years, SD ± 11.6 underwent sTIPS which controlled bleeding in 32 (94%) patients. Ten (29.4%) patients died in hospital at a median of 4.8 (range 1-10) days. On bivariate analysis, C-P score ≥ 10 (p = 0.017), high C-P grade (p = 0.048), MELD ≥ 15 (p = 0.010), MELD-Na score ≥ 22 (p < 0.001) and APACHE II score ≥ 15 (p < 0.001) predicted 90-day mortality. Individual clinical characteristics associated with 90-day mortality were grade 3 ascites (p = 0.029), > 10 units of blood transfused (p = 0.004), balloon tube placement (p < 0.001), endotracheal intubation (< 0.001) and inotrope support (p < 0.001). The overall 90-day, 1-, 3- and 5-year survival rates were 67.6%, 55.9%, 26.5% and 20.6% respectively. Nine patients (26.5%) were alive at a median of two years (range 1-18 years) post-TIPS. Patients with C-P grade A, C-P score < 10, MELD score < 15, MELD-Na score < 22 and APACHE II score < 15 had significantly better 90-day, 1-, 3- and 5-year survival rates. CONCLUSION: Although sTIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy, in-hospital mortality was 29% and less than one quarter were alive after five years. The selected cut-off values for the nominated scoring systems accurately predicted 90-day mortality and long-term survival.

Audit of an in-patient palliative care quality improvement process for patients with pancreatic ductal adenocarcinoma in a South African teaching hospital.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor survival rates. Timeously introduced palliative care (PC) improves the quality of life (QoL) for patients with terminal diseases. In 2020, an in-patient PC-quality improvement (QI) programme was implemented for PDAC patients. This study compared PC outcomes before and after the introduction of the PC-QI programme. METHODS: A focus group identified five critical intervention areas that could improve care. These were in-patient PC referral, pain and symptom control, shared decision-making, interdisciplinary collaborative care, and continuity of care. A hospital record audit of PDAC patients was conducted in pre- and post-implementation cohorts, and the results were compared. RESULTS: A total of 68 (2017 pre-PC-QI) and 39 (2022 post-PC-QI) patient records were audited. Demography, symptom duration, referral delay, and clinical findings were similar in both cohorts. In-patient PC referrals improved significantly from 54.4% in 2017 to 82.1% in 2022 (p = 0.0059). Significant improvements were also recorded in shared decisionmaking, collaboration, and continuity of care, while the reassessment of pain and symptoms after treatment improved. Fewer invasive procedures were done in the 2022 cohort (p = 0.0056). The delay from admission to an invasive diagnostic procedure decreased from a mean of 8.7 to 1.5 days (p = 0.0001). The duration of hospital admission, overall survival (OS), and readmissions during the final 30 days of life were similar. CONCLUSION: The QI programme resulted in improved use of the in-hospital PC service and made better use of scarce resources. Increasing patient and family participation and feedback will further inform the development of the quality of PC services.

Inflammatory myofibroblastic tumours of the liver - a systematic review.

BACKGROUND: Hepatic inflammatory myofibroblastic tumours (HIMTs) are rare and poorly described in the literature. Most publications are single patient case reports and lack detailed reporting on characteristics, management, and outcomes. This systematic review aimed to assess the demography, clinical presentation, typical imaging features, histopathology, treatment, and outcomes of patients presenting with HIMTs. METHODS: A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Scopus), JSTOR, Cochrane CENTRAL (Cochrane Library), and the databases included in the Web of Science for studies published between 1940 and 2023 on HIMTs, including its reported synonyms. Case series or cohort studies that reported on the management and outcomes of at least four patients with histologically confirmed HIMTs were included in the analysis. RESULTS: After screening 4553 publications, 22 articles including a total of 440 patients with confirmed HIMTs were eligible for inclusion. The average age was 53.4 years (range 42.0-65.0) with a male to female ratio of 1.7:1. Abdominal pain, discomfort, fever, and loss of weight were the most common presenting symptoms. Surgical resection is the standard of care for HIMTs and is associated with low mortality of 3.4% and low disease recurrence. CONCLUSION: HIMT is a disease more often affecting middle-aged males. The lesions are typically solitary with low recurrence after treatment. The relative roles of surgical versus medical treatment remain unclear. Differences in clinical presentation, histopathology, and treatment of HIMTs compared to inflammatory myofibroblastic tumour (IMT) at extrahepatic sites could challenge the current view of IMT as a single pathological entity.

Complex bile duct injuries after laparoscopic cholecystectomy: a comparative outcomes analysis of patients treated in tertiary private and public health facilities in Cape Town, South Africa.

BACKGROUND: The South African healthcare system has an under-financed public sector serving most of the population and a better resourced private sector serving a small fraction of the population. This study evaluated management and outcome in patients with complex bile duct injuries (BDIs) after laparoscopic cholecystectomy referred from either private or public hospitals. METHOD: The data of patients who underwent hepaticojejunostomy repair were retrieved from a prospectively maintained central departmental BDI database. Patients were treated either in the Surgical Gastroenterology Unit at Groote Schuur Hospital, University of Cape Town (UCT) or the Digestive Diseases Centre, UCT Private Academic Hospital by the same hepatobiliary surgical team. Relevant preoperative clinical data and postoperative complications and outcomes were compared between patients originating either in the public or private sector. RESULTS: One hundred and twenty-five patients were included, 58 from the public and 67 from the private sector. The type of BDI, time to diagnosis, referral and repair were similar. Patients referred from the private sector underwent more percutaneous cholangiograms prior to referral (11.9% vs 1.7%, p = 0.037). Patients referred from the public sector underwent more CT examinations (p = 0.044) and endoscopic retrograde cholangiography (p = 0.038) after admission to our centre. There were no statistically significant differences in 30-day postoperative complications. Primary patency rates were similar for public and private referrals (90% vs 88%, respectively). There were two BDI-related mortalities at 90 days. CONCLUSION: Despite differences in public and private healthcare system resources, patients were referred early and appropriately from both sectors and had similar postoperative outcomes when treated in a specialised unit.

Resection of benign liver tumours: an analysis of 62 consecutive cases treated in an academic referral centre.

BACKGROUND: Benign tumours of the liver are increasingly diagnosed and constitute a substantial proportion of all hepatic tumours evaluated and resected at tertiary referral centres. This study assessed the safety and outcome after resection of benign liver tumours at a major referral centre. METHOD: All patients with symptomatic benign liver tumours who underwent resection were identified from a prospective departmental database of a total of 474 liver resections (LRs). Demographic data, operative management and morbidity and mortality using the Accordion classification were analysed. RESULTS: Sixty-two patients (56 women, 6 men, median age 45 years, range 17-82) underwent resection of symptomatic haemangiomata n=23 (37.1%), focal nodular hyperplasia n=19 (30.6%), biliary cystadenoma n=16 (25.8%) and hepatic adenomas n=4 (6.5%). A major resection was required in 25 patients, 14 patients had 4 segments resected, 11 had 3 segments and 37 patients had 2 or fewer segments resected. Median operating time was 169 minutes (range 80-410). Median blood loss was 300 ml (range 50-4500 ml) and an intra-operative blood transfusion was required in 6 patients. Median length of post-operative hospital stay was 7 days (range 4-32). Complications occurred in 11 patients (Accordion grades 1 n=1, 2 n=4, 3 n=1, 4 n=4, 6 n=1). Four patients required re-operation (bleeding n=2, bile leak n=1, small bowel obstruction n=1). An elderly patient died in hospital on day 16 following a postoperative cerebrovascular accident. CONCLUSION: Clinically relevant symptomatic benign liver tumours comprise a substantial proportion of LRs. Our data suggest that resections can be performed safely with minimal blood loss and transfusion requirements. We advocate selective resection according to established indications. Despite the low postoperative mortality rate, the risk of postoperative complications emphasizes the need for careful selection of patients for resection.

Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic Level 1 trauma centre.

BACKGROUND: This study evaluated factors influencing mortality in a large cohort of patients who sustained pancreatic injuries and underwent DCS. METHODS: A prospective database of consecutive patients with pancreatic injuries treated at a Level 1 academic trauma centre was reviewed to identify those who underwent DCS between 1995 and 2014. RESULTS: Seventy-nine (71 men, median age: 26 years, range 16-73 years, gunshot wounds = 62, blunt = 14, stab = 3) patients with pancreatic injuries (35 proximal, 44 distal) had DCS. Fifty-nine (74.7 %) patients had AAST grade 3, 4 or 5 pancreatic injuries. The 79 patients had a total of 327 associated injuries (mean: 3 per patient, range 0-6) and underwent a total of 187 (range 1-7) operations. Vascular injuries (60/327, 18.3 %) occurred in 41 patients. Twenty-seven (34.2 %) patients died without having a second operation. The remaining 52 patients had two or more laparotomies (range 2-7). Overall 28 (35 %) patients underwent a pancreatic resection either during DCS (n = 18) or subsequently as a secondary procedure (n = 10) including a Whipple (n = 6) when stable. Overall 43 (54.4 %) patients died. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.01) and combined vascular and total number of associated organs injured (p < 0.04). CONCLUSIONS: Despite the magnitude of their combined injuries and the degree of physiological insult, DCS salvaged 45 % of critically injured patients who later underwent definitive pancreatic surgery. Mortality correlated with associated vascular injuries overall, major visceral venous injuries and the combination of vascular plus the total number of associated organs injured.

Incidence and management of postoperative bile leaks: A prospective cohort analysis of 467 liver resections.

BACKGROUND: Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection. PATIENTS AND METHODS: A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications. RESULTS: Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks. CONCLUSION: The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.

Isolated pancreatic injuries: An analysis of 49 consecutive patients treated at a Level 1 Trauma Centre.

BACKGROUND: This study interrogated a large prospectively documented institutional database to determine morbidity and mortality after an isolated pancreatic injury (IPI). METHOD: Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. The degree of the pancreatic duct injury was graded using a modified Takishima duct injury classification. Primary endpoints were general and pancreas-specific morbidity and mortality. RESULTS: Four hundred and forty-eight consecutive patients were treated between 1990 and 2014 for pancreatic injuries of whom 49 (median age: 30, range: 13-68 years, 41 men, blunt injuries: n=43) had an IPI. Thirty-four (70%) patients underwent urgent surgery, 20 of whom had a distal pancreatectomy and 14 had external drainage of the pancreatic injury. Fifteen (30%) patients presented with a non-resolving pancreatic pseudocyst or fistula; five had grade 4A or 4B ductal injuries and underwent surgery, 10 with 3A and 3B ductal injuries were successfully managed endoscopically. Fifty-five percent had postoperative morbidity. Two patients (4%) died of non-pancreatic-related causes. CONCLUSION: While overall mortality is low after an IPI, morbidity is high. Two thirds of patients required operative intervention and one third were treated endoscopically. The degree of pancreatic ductal injury determined whether endoscopic intervention was effective.

Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre.

BACKGROUND: This study evaluated the efficacy of endoscopic treatment of delayed local complications including pseudocysts and persistent pancreatic fistulae in a cohort of civilian patients who had previously sustained a pancreatic injury. METHOD: A large institutional database was interrogated to identify patients who developed a delayed pancreatic complication among those with pancreatic injuries treated between January 1990 and December 2013. The degree of the pancreatic duct injury was graded using a new duct injury grading system and endoscopic therapeutic outcome assessed according to the grade of injury. RESULTS: During the period under review, 432 consecutive patients were treated for pancreatic injuries of whom 27 (20 men, 7 women, median age 31, range 15-68 years) presented with delayed complications related to the initial pancreatic injury. Sixteen patients had non-resolving symptomatic pancreatic pseudocysts, 10 had persistent pancreatic fistulae and 1 had a symptomatic duct stricture. Fourteen patients with grade 2a, 3a, 3b or 4c main pancreatic duct injuries were successfully treated endoscopically with either pancreatic duct stenting or pseudocyst drainage while 13 patients with grade 4a or 4b duct injuries who had complete duct division with a disconnected duct syndrome failed endoscopic management and required surgical intervention. The 27 patients underwent a total of 49 endoscopic procedures (47 elective, 2 emergency) of whom 4 developed complications related to the endoscopic treatment. All 4 resolved, 2 after urgent endoscopic re-intervention. CONCLUSION: In this preliminary analysis the Cape Town pancreatic ductal injury grading classification showed a close correlation with outcome after endoscopic and operative intervention.

Prognostic factors, morbidity and mortality in pancreatic trauma: a critical appraisal of 432 consecutive patients treated at a Level 1 Trauma Centre.

BACKGROUND: This large retrospective observational cohort study evaluated prognostic factors, 30-day morbidity and mortality and complications related to the pancreas in patients who had sustained pancreatic injuries. METHODS: The records of 432 consecutive patients treated for pancreatic injuries at an urban Level 1 Trauma Centre in Cape Town between January 1982 and December 2012 were reviewed. Primary endpoints were postoperative morbidity and death. Bivariate and multivariate logistic regression analyses were used to assess significant predictors of morbidity and mortality. RESULTS: Overall mortality in 432 patients [394 men, median age 26, median RTS 7.8] was 15.7% and morbidity 66%. Bivariate logistic regression analysis showed that nine factors, age, RTS, presence of shock, need for a transfusion, volume of blood transfused, damage control surgery, AAST grade of pancreatic injury, an associated vascular injury and a repeat laparotomy were significant predictors of morbidity. In the final multivariate logistic regression analysis model however only two variables, AAST grade of pancreatic injury and a repeat laparotomy were significant predictors of morbidity. When factors associated with mortality were considered, logistic regression analysis found that 11 variables, age, RTS, the presence of shock, patients who required a major blood transfusion, the median number of units transfused, the need for a damage control laparotomy, AAST grade 3, 4, 5 pancreatic injuries, associated vascular injuries, the number of associated injuries, postoperative complications and days in ICU were significant. However in the final stepwise multivariate logistic regression analysis model only five variables, age, shock, median number of units transfused and the presence of associated complications were significant factors associated with mortality. CONCLUSIONS: Morbidity was 64% and AAST grade of pancreatic injury and a repeat laparotomy were significant predictors of morbidity. Overall mortality was 15.7%. Most deaths were due to associated injuries and were unrelated to the pancreatic injury. Five variables, age, shock, median number of units transfused and the presence of associated complications were significant factors associated with mortality. These data indicate that the magnitude of blood loss and haemorrhagic shock are primary determinants for survival and that urgent reversal of shock and control of bleeding are essential to reduce mortality in this cohort of patients.

An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries.

INTRODUCTION: Penetrating injuries of the pancreas may result in serious complications. This study assessed the factors influencing morbidity after stab wounds of the pancreas. METHODS: A retrospective univariate cohort analysis was carried out of 78 patients (74 men) with a median age of 26 years (range: 16-62 years) with stab wounds of the pancreas between 1982 and 2011. RESULTS: The median revised trauma score (RTS) was 7.8 (range: 2.0-7.8). Injuries involved the body (n=36), tail (n=24), head/uncinate process (n=16) and neck (n=2) of the pancreas. All 78 patients underwent a laparotomy. Sixty-five patients had AAST (American Association for the Surgery of Trauma) grade I or II pancreatic injuries and thirteen had grade III, IV or V injuries. Eight patients (10.3%) had an initial damage control operation. Sixty-nine patients (84.6%) had drainage of the pancreas only, six had a distal pancreatectomy and one had a pancreaticoduodenectomy. Most pancreas related complications occurred in patients with AAST grade III injuries; eight patients (10.2%) developed a pancreatic fistula. Four patients (5.1%) died. Grade of pancreatic injury (AAST grade I-II vs grade III-V injuries, p<0.001), RTS (odds ratio [OR]: 5.01, 95% confidence interval [CI]: 1.46-17.19, p<0.007), presence of shock on admission (OR: 3.31, 95% CI: 1.16-9.42, p=0.022), need for a blood transfusion (OR: 6.46, 95% CI: 2.40-17.40, p<0.001) and repeat laparotomy (p<0.001) had a significant influence on the development of general complications. CONCLUSIONS: Although mortality was low after a pancreatic stab wound, morbidity was high. Increasing AAST grade of injury, high RTS, shock on admission to hospital, need for blood transfusion and repeat laparotomy were significant factors related to morbidity.

Morbidity and mortality after distal pancreatectomy for trauma: a critical appraisal of 107 consecutive patients undergoing resection at a Level 1 Trauma Centre.

BACKGROUND: This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy. STUDY DESIGN: Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien-Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. RESULTS: A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n=26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14±39.4 days. CONCLUSIONS: Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien-Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II-IV injuries (p<0.05).

Surgical management and outcome of civilian gunshot injuries to the pancreas.

BACKGROUND: Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds. METHODS: This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed. RESULTS: A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I-II (111 patients) and grade III-V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19.6 per cent) required an initial damage control procedure. A total of 150 patients (68.5 per cent) had 407 postoperative complications (median 4, range 1-7). The 46 patients (21.0 per cent) who died had a median of 3 (range 1-7) complications. Median (range) intensive care unit and total hospital stay were 5 (1-153) and 11 (1-255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality. CONCLUSION: Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death.

Pancreatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre.

BACKGROUND AND OBJECTIVE: Injuries to the pancreas are uncommon, but may result in considerable morbidity and mortality. This study evaluated the management of blunt pancreatic injuries using a previously defined protocol to determine which factors predicted morbidity and mortality. METHODS: The study design was a retrospective chart review of all adult patients with blunt pancreatic injuries treated at a level 1 trauma centre between March 1981 and June 2009. RESULTS: One hundred and ten patients (92 men, 18 women; mean age 30 years, range 13-68 years) were treated during the study period. Forty-six patients had American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 64 had AAST grade 3, 4 or 5 pancreatic injuries. Injuries involved the head (N=21), neck (N=15), body (N=48) and tail (N=26) of the pancreas. The mean number of organs injured was 2.7 per patient (range 1-4). One hundred and one patients underwent a total of 123 operations, including drainage of the pancreatic injury (N=73), distal pancreatectomy (N=39) and Whipple resection (N=5). The overall complication rate was 74.5% and the mortality rate 16.4%. Only 2 of the 18 deaths were attributable to the pancreatic injury. Shock on presentation was highly predictive of death; 17 of 39 patients with shock died, compared with 1 of 71 patients who were not shocked (p < 0.0001). Fourteen of 46 patients with grade 1 and 2 pancreatic injuries died compared with 4 of 64 patients with grades 3, 4 and 5 injuries (p < 0.001). Mortality increased exponentially as the number of associated injuries increased. Two of 57 patients with injury to the pancreas only or one associated injury died, compared with 16 of 53 with two or more associated injuries (p < 0.0013). CONCLUSIONS: This study demonstrated a significant correlation between the AAST grade of injury and pancreas-specific morbidity and between shock on admission, the number of associated injuries and death, in patients with blunt pancreatic injuries. Although morbidity and mortality rates after blunt pancreatic trauma are high, death was usually the result of major associated injuries and not related to the pancreatic injury.

Early rebleeding and death at 6 weeks in alcoholic cirrhotic patients with acute variceal bleeding treated with emergency endoscopic injection sclerotherapy.

BACKGROUND: This study evaluated the incidence of rebleeding and death at 6 weeks after a first episode of acute variceal haemorrhage (AVH) treated by emergency endoscopic sclerotherapy in a large cohort of alcoholic cirrhotic patients. METHODS: From January 1984 to December 2006, 310 alcoholic cirrhotic patients (242 men, 68 women; mean age 51.7 years) with AVH underwent 786 endoscopic variceal injection treatments (342 emergency, 444 elective) during 919 endoscopy sessions in the first 6 weeks after the first variceal bleed. Endoscopic control of initial bleeding, variceal rebleeding and survival at 6 weeks were recorded. RESULTS: Endoscopic intervention controlled AVH in 304 of 310 patients (98.1%). Seventy-five patients (24.2%) rebled, 38 (12.3%) within 5 days and 37 (11.9%) within 6 weeks. No patient scored as Child-Pugh A died. Seventy-seven (24.8%) Child-Pugh B and C patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days. Mortality increased exponentially as the Child-Pugh score increased, reaching 80% when the score exceeded 13. CONCLUSION: Despite initial control of variceal haemorrhage, 1 in 4 patients (24.2%) rebled within 6 weeks. Survival at 6 weeks was 75.2% and was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients.