Hypertriglyceridaemia as a risk factor for critical care admission in acute pancreatitis: A prospective study.

BACKGROUND AND AIMS: Hypertriglyceridaemia is both a primary cause of acute pancreatitis and an epiphenomenon. This study aimed to define the associations between hypertriglyceridaemia and clinical outcomes in patients admitted with acute pancreatitis. METHODS: This single-centre prospective observational study included patients with a confirmed clinical, biochemical or radiological diagnosis of acute pancreatitis from August 2017 to September 2018. Baseline demographics, aetiology of pancreatitis, and fasting triglyceride concentrations were recorded and assessed against the surrogate markers of severity: admission to critical care, length of stay (LOS), readmission to hospital, and mortality. RESULTS: In total, 304 patients with a mean ± SD age of 56.1 ± 19.7 years met the inclusion criteria. There were 217 (71.4%) patients with normotriglyceridaemia (<150 mg/dL or <1.7 mmol/L), 47 (15.5%) with mild hypertriglyceridaemia (150-199 mg/dL or 1.7-2.25 mmol/L) and 40 (13.2%) with moderate-to-severe hypertriglyceridaemia (≥200 mg/dL or >2.25 mmol/L). The underlying aetiologies of acute pancreatitis were gallstones (55%), alcohol (18%), idiopathic (15%), hypertriglyceridaemia (9%), iatrogenic (2%) and bile duct abnormalities (1%). Patients with hypertriglyceridaemia were younger than those with normotriglyceridaemia (p < 0.05). On multivariate regression, moderate-to-severe hypertriglyceridaemia (OR 5.66, 95% CI: 1.87 to 17.19, p = 0.002) and an elevated C-reactive protein concentration ≥120 mg/L (OR 1.00, 95% CI: 1.00-1.01, p = 0.040) were associated with admission to critical care. Moderate-to-severe hypertriglyceridaemia was also associated with an increased LOS (p = 0.002) but not readmission (p = 0.752) or mortality (p = 0.069). CONCLUSION: Moderate-to-severe hypertriglyceridaemia in all aetiological causes of acute pancreatitis was predictive of admission to critical care and prolonged LOS but not readmission or mortality.

Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study.

PURPOSE: To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration. METHODS: Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days. RESULTS: 154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8-3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3-3.7 days). Grade III-V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1-78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2-55.1, p = 0.004). CONCLUSIONS: Higher grade injuries (III-V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.

Spectral and raw quasi in-situ energy dispersive X-ray data captured via a TEM analysis of an ODS austenitic stainless steel sample under 1 MeV Kr2+ high temperature irradiation.

The data presented in this article is related to the research experiment, titled: 'Quasi in-situ energy dispersive X-ray spectroscopy observation of matrix and solute interactions on Y-Ti-O oxide particles in an austenitic stainless steel under 1 MeV Kr2+ high temperature irradiation' (Brooks et al., 2017) [1]. Quasi in-situ analysis during 1 MeV Kr2+ 520 °C irradiation allowed the same microstructural area to be observed using a transmission electron microscope (TEM), on an oxide dispersion strengthened (ODS) austenitic stainless steel sample. The data presented contains two sets of energy dispersive X-ray spectroscopy (EDX) data collected before and after irradiation to 1.5 displacements-per-atom (~1.25×10-3 dpa/s with 7.5×1014 ions cm-2). The vendor software used to process and output the data is the Bruker Esprit v1.9 suite. The data includes the spectral (counts vs. keV energy) of the quasi in-situ scanned region (512×512 pixels at 56k magnification), along with the EDX scanning parameters. The.raw files from the Bruker Esprit v1.9 output are additionally included along with the.rpl data information files. Furthermore included are the two quasi in-situ HAADF images for visual comparison of the regions before and after irradiation. This in-situ experiment is deemed 'quasi' due to the thin foil irradiation taking place at an external TEM facility. We present this data for critical and/or extended analysis from the scientific community, with applications applying to: experimental data correlation, confirmation of results, and as computer based modeling inputs.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies.

AIM: To investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up. METHODS: Neoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed. RESULTS: Twenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively). CONCLUSION: PPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Military general surgical training opportunities on operations in Afghanistan.

INTRODUCTION: In the UK, general surgical specialist trainees have limited exposure to general surgical trauma. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees. PATIENTS AND METHODS: A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available. RESULTS: A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies. CONCLUSIONS: A training opportunity currently exists on Operation HERRICK for military general surgical specialist trainees. If the tempo of the last 12 months is maintained, a 2-month deployment would essentially provide trainees with the equivalent trauma surgery experience to the whole of their surgical training in the UK NHS. Trainees would gain experience in military trauma as well as specific organ injury management.

Is a T-tube necessary after common bile duct exploration?

BACKGROUND: T-tube drainage used to be standard practice after surgical choledocholithotomy, but there is now a tendency in some centers to close the common bile duct (CBD) primarily. This study was designed to review the complications associated with T-tube drainage after CBD exploration and to determine whether primary closure of the bile duct reduces postoperative morbidity. METHODS: A retrospective audit was performed on patients undergoing CBD exploration between July 1997 and March 2007, who were identified from the theatre database of one teaching hospital. Intraoperative findings and postoperative complications were recorded from the clinical notes. RESULTS: During the study period, 158 patients (97 women; median age 65 (range, 25-90) years) underwent CBD exploration. A T-tube was inserted in 91 patients (group I) and the CBD was closed primarily in 67 (group II). One or more biliary complications occurred in 26 patients (16.5%): 20 (22.0%) in group I and 6 (8.9%) in group II (p = 0.03). In group I, 15 had a biliary leak (3 needed reoperation), 2 had accidental slippage of the tube, 2 an entrapped T-tube, and 1 a retained stone. In group II, six patients had biliary leakage, two of whom were re-explored. Six patients in group I also had peritubal infection, necessitating the use of antibiotics. There were three deaths: two in group I (1 T-tube-related) and 1 in group II (p = 1, not significant). CONCLUSION: There is a lower biliary complication rate associated with primary closure of the CBD than after T-tube drainage.

The effect of hepatic vascular inflow occlusion on liver tissue pH, carbon dioxide, and oxygen partial pressures: defining the optimal clamp/release regime for intermittent portal clamping.

BACKGROUND: The optimal duration of hepatic vascular inflow occlusion (Pringle maneuver) and reperfusion during liver resection are not defined. The aim of this study was to describe the changes that occur in liver tissue pH, partial pressure of carbon dioxide (P(L)CO(2)), and partial pressure of oxygen (P(L)O(2)) and by using the P(L)CO(2) as a predictor of hepatocellular damage define the optimal clamp/release regime for intermittent portal clamping during liver resection. METHODS: Continuous pH, P(L)CO(2), and P(L)O(2) measurements were obtained using a Paratrend multi-parameter sensor (Diametrics Medical Inc., Roseville, MN) in 13 patients undergoing elective partial liver resection. Patients were randomly allocated to undergo a 10-min clamp/5-min release regime (group 1) or a 20-min clamp/10-min release regime (group 2). RESULTS: In group 1 (n = 6) P(L)CO(2) increased and pH decreased significantly after 10 min of clamping and returned to baseline within 5 min of reperfusion. In group 2 (n = 7) the P(L)CO(2) increased and pH decreased significantly after 10 min of clamping, with a further significant change after 20 min. Following 10 min of reperfusion, pH and P(L)CO(2) had not returned to baseline. P(L)O(2) did not change significantly with either intermittent portal clamping regime. CONCLUSIONS: A reperfusion of 5 min is sufficient to restore the P(L)CO(2) and liver tissue pH to normal after 10 min of clamping, but more than 10 min of reperfusion is required after 20 min of clamping. To minimize hepatic ischemia during liver resection, a 10-min clamp/5-min release regime should be used.

Improving performance in the management of severely injured patients in critical care.

OBJECTIVE: To determine opportunities for improvement (OI) in the critical care management of severely injured patients in a general adult intensive care unit through a performance improvement (PI) process. METHODS: Retrospective review of patient records from intensive care patients who had sustained traumatic injuries, except isolated head injury, over a 1-year period. Three assessors independently audited the notes using performance improvement methodology to determine complications, errors in management and preventability. Complications were included when two or more assessors independently detected the complication. MEASUREMENTS AND RESULTS: Records from 90 patients with a diagnosis of 'trauma' were reviewed, 14 patients with isolated head injury were excluded. The mean injury severity score was 23 (range 4-43). No complications or errors of management were identified from 41 patients, including ten patients who died. Seventy-two complications were identified in 35 patients including 15 pneumonias, 6 cases of peri-operative hypothermia and 5 recurrent pneumothoraces. Fourteen preventable complications were identified. CONCLUSIONS: The PI OI process highlighted specific opportunities for the improvement of critical care management of trauma patients in our unit. These will be addressed through the introduction of formal tertiary surveys and clinical management guidelines addressing hypothermia and management of coagulopathy.

Acute pancreatitis following liver resection: report of three fatal cases and a review of the literature.

Pancreatitis is a well recognised but rare complication following liver resection. The precise aetiology is not well understood and the clinical diagnosis may frequently be obscured by the postoperative state. Postoperative pancreatitis has a high mortality rate and should always be considered in patients who unexpectantly deteriorate postoperatively. We present three fatal cases of pancreatitis following liver resection. The literature is reviewed to elucidate common factors in patients who develop postoperative pancreatitis.