Successful management of a large air embolus during an extended right hepatectomy with an emergency cardiopulmonary bypass.

BACKGROUND: An air embolus is a recognized but rare complication of a partial hepatectomy. The aim of this report was to describe the diagnosis and management of a large paradoxical air embolus during hepatic resection. METHODS: Case report. RESULTS: A single patient report of a massive paradoxical air embolus during an extended right hepatectomy is described. The diagnosis was confirmed by trans-oesophageal echo (video provided). After failed conservative management an emergency cardiopulmonary bypass was instituted with a successful outcome. CONCLUSION: Surgeons and anaesthetists involved in hepatic surgery should be aware of signs, investigations and management of this life-threatening intra-operative complication.

C-reactive protein is a useful negative predictor of anastomotic leak in oesophago-gastric resection.

BACKGROUND: Post-operative C-reactive protein (CRP) has been investigated as a predictor of anastomotic leak (AL) following colorectal surgery, but its role in oesophago-gastric surgery is not yet established. METHODS: Clinical data and post-operative CRP values of patients who underwent elective oesophago-gastric resection between January 2004 and July 2014 were analysed retrospectively. Only patients with an oesophageal anastomosis were included. AL was defined as leakage of contrast material seen on imaging or a leak confirmed intraoperatively on return to theatre. RESULTS: One hundred and forty-five patients were identified. Of the 145 patients, 13 (9%) developed AL. The CRP on post-operative days (POD) 2, 3 and 6 had the greatest diagnostic accuracy, with an area under the curve of 0.82, 0.80 and 0.91 respectively. Using a cut-off value of 209 mg/L on POD 2, the sensitivity was 100%, the specificity was 61%, the positive predictive value (PPV) was 21% and the negative predictive value (NPV) was 100%. Using a cut-off value of 190 mg/L on POD 3, the sensitivity was 100%, the specificity was 59%, the PPV was 21% and the NPV was 100%. Using a cut-off value of 154 mg/L on POD 6, the sensitivity was 100%, the specificity was 78%, the PPV was 29% and the NPV was 100%. CONCLUSION: Post-operative CRP is an accurate negative predictive test for the development of AL following oesophago-gastric surgery. It may help to discriminate between patients with a high risk of leak and those in which AL is unlikely to occur.

Predicting malignancy in adrenal incidentaloma and evaluation of a novel risk stratification algorithm.

BACKGROUND: Incidentally discovered adrenal lesions known as adrenal incidentalomas (AI) are being encountered with increasing frequency due to the widespread use of abdominal computed tomography (CT). The aim of this study was to identify the clinical predictors of malignancy in AI and to evaluate the accuracy of a recently proposed risk stratification algorithm. METHODS: A retrospective analysis of 96 patients presenting with AI between 2004 and 2014 was undertaken; 66 patients underwent adrenalectomy, and 30 were managed non-operatively. Univariate analysis including patient demographics, CT features of tumour size, density and heterogeneity was performed. Hormonal parameters including 24-h urinary-free cortisol and serum dehydroepiandrosterone sulphate (DHEAS) were also included. A Cleveland Clinic risk stratification model utilizing adrenal size and density was evaluated. RESULTS: The overall rate of malignancy was 8%. On univariate analysis, the following preoperative variables were predictive of malignancy - tumour size on pathology (P = 0.0031) and CT (P = 0.0016), heterogeneity on CT imaging (P = 0.0036), a relative percentage washout of less than 40% (P = 0.0178), elevated 24-h urinary-free cortisol levels (P = 0.0176), elevated DHEAs (P = 0.0061) and younger age at presentation (P < 0.0001). Evaluation of the Cleveland Clinic algorithm found an area under the receiver operating characteristic curve of 0.81 (95% confidence interval 0.52-1.00). CONCLUSION: CT characteristics of tumour size, density and heterogeneity are significantly associated with malignancy in AI and applied together reliably exclude malignancy. The risk stratification algorithm utilizing size and density alone may fail to identify some smaller adrenal cancers.

Long-term outcomes of hepatic resection for colorectal liver metastases at a New Zealand tertiary level public hospital.

BACKGROUND: Colorectal cancer is common with half of all patients developing metastases to the liver. The aim of this study was to document the survival for patients undergoing liver resection for colorectal cancer metastases. METHOD: A review of all patients undergoing hepatic resection for colorectal liver metastases at a New Zealand tertiary level public hospital over a 9-year period was performed. RESULTS: Primary survival outcomes assessed were overall survival (OS) and disease-free survival (DFS). Of the 116 patients followed-up with a median (range) of 53 (10-116) months, the OS at 5 years was 53%. Median survival was 6.5 years. At end of follow-up, 57% of patients were alive and 49% were alive without recurrence. The overall rate of recurrence was 39%. CONCLUSION: This study confirms that excellent long term survival can be achieved with hepatic resection for colorectal liver metastases.

Mobile task management tool that improves workflow of an acute general surgical service.

BACKGROUND: Understanding and being able to measure constraints within a health system is crucial if outcomes are to be improved. Current systems lack the ability to capture decision making with regard to tasks performed within a patient journey. The aim of this study was to assess the impact of a mobile task management tool on clinical workflow within an acute general surgical service by analysing data capture and usability of the application tool. METHODS: The Cortex iOS application was developed to digitize patient flow and provide real-time visibility over clinical decision making and task performance. Study outcomes measured were workflow data capture for patient and staff events. Usability was assessed using an electronic survey. RESULTS: There were 449 unique patient journeys tracked with a total of 3072 patient events recorded. The results repository was accessed 7792 times. The participants reported that the application sped up decision making, reduced redundancy of work and improved team communication. The mode of the estimated time the application saved participants was 5-9 min/h of work. Of the 14 respondents, nine discarded their analogue methods of tracking tasks by the end of the study period. CONCLUSION: The introduction of a mobile task management system improved the working efficiency of junior clinical staff. The application allowed capture of data not previously available to hospital systems. In the future, such data will contribute to the accurate mapping of patient journeys through the health system.