Laparoscopic cholecystectomy prevents readmissions. A 9-year review of acute pancreatitis in pregnancy in an Australian tertiary center.

BACKGROUND: Acute pancreatitis in pregnancy (APIP) is a rare but potentially life-threatening condition, affecting women at any gestation. The aim of this review is to investigate the demographics, etiology, management, and outcomes of pancreatitis in pregnant women in a major tertiary hospital in Queensland. METHODS: Data was collected from the hospital medical records of all patients diagnosed with APIP from 01/01/2012 until 30/04/2021 at the Mater Hospital, Brisbane. Descriptive statistical measures were employed. Spearman's rank correlation was used to challenge different risk factors for readmission. RESULTS: 26 patients met the inclusion criteria, with 38 admissions during the study period. Biliary pancreatitis was the most common etiology (n = 14, 53.8%). 42.5% of admissions were managed operatively (n = 15). 38.5% of patients had more than one admission (n = 10). Undergoing a laparoscopic cholecystectomy on index admission correlated with a significantly lower chance of repeat admission (rs= -.48, p = .013, CI = - .737 to -.102). CONCLUSION: This is the first study of this condition in an Australian institution. It demonstrates that in patients with acute biliary pancreatitis, operative management can be safely employed at any trimester and laparoscopic cholecystectomies should be performed in the index admission to reduce the risk of readmission to hospital.

The Abdominal Reapproximation Anchor Device.

INTRODUCTION: Achieving primary fascial closure after damage control laparostomy can be challenging. A number of devices are in use, with none having yet emerged as best practice. In July 2013, at Westmead Hospital, we started using the abdominal reapproximation anchor (ABRA; Canica Design, Almonte, Ontario, Canada) device. We report on our experience. METHODS: A retrospective review of medical records for patients who had open abdomens managed with the ABRA device between July to December 2013 was done. Data extracted included age, sex, body mass index (BMI), reason for the open abdomen, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of laparostomies prior to ABRA placement, duration of placement, device complications, length of hospital and intensive care unit (ICU) stay, and outcomes. RESULTS: Four cases of open abdomens managed using the ABRA device were identified, with 3 a consequence of intra-abdominal sepsis and 1 a consequence of penetrating trauma. Mean BMI was 33.5 kg/m2, APACHE II score was 14.5, duration with open abdomen prior to ABRA placement was 11.75 days, duration with ABRA in situ was 9 days, duration of hospital stay was 64.25 days, and ICU stay was 37.75 days. Three patients (75%) achieved fascial closure, and 1 achieved skin closure. No incidences of enterocutaneous fistulae occurred. CONCLUSION: The ABRA is a unique emerging alternative to aid in achieving fascial closure in patients managed with open abdomens. Our case series demonstrates that it can be used effectively in selected patients. Studies are needed to compare its efficacy with more traditional methods.

High-grade dysplasia of the cystic duct margin: how should this be managed?

High-grade dysplasia (HGD) in the cystic duct is a rare epithelial lesion that may lead to biliary tract malignancy. Due to its association with aggressive multifocal cholangiocarcinoma, it is important to investigate for concurrent malignancy, remove all areas of HGD and monitor for recurrence or metastasis.We present a case of a woman in her 60s with cholecystitis who underwent a laparoscopic cholecystectomy. On histopathology, the patient was found to have incidental HGD involving the cystic duct margin. After ensuring the absence of concurrent malignancy on cross-sectional imaging, she underwent further resection until the margins were clear of dysplasia. In the absence of clear follow-up guidelines, the patient was closely monitored with outpatient scans for up to 5 years.

Hepatic small vessel neoplasm - A systematic review.

BACKGROUND: Hepatic small vessel neoplasm (HSVN) is a recently described vascular neoplasm of the liver that can mimic hepatic angiosarcoma (AS) because of its infiltrative nature but is considered biologically less aggressive. We carried out a systematic review of the literature after previously coming across a case of HSVN [1] to guide our surveillance. METHODS: We conducted a systematic review for all cases using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, case report journals and Google Scholar according to the PRISMA guidelines using the terms "hepatic small vessel neoplasm" or "hepatic small vessel neoplasia" with no language restrictions. The review was registered with Research Registry (UIN: reviewregistry1127) [2]. RESULTS: We identified 69 articles, of which 6 articles were eligible after screening. A total of 23 cases were identified. Median age was 58 (range 24-83 years) with a male preponderance (17 M:6F). Mean tumour size was 2.8 cm (range 0.2-15.9 cm). Mean follow-up was 7 months (range 1-24 months) with no reported evidence of recurrence in both patient groups with no residual disease or with positive margins after resection. DISCUSSION: HSVN appears to demonstrate a benign clinical course with no reported recurrences or metastatic disease. Long-term follow-up data will further supplement our understanding of these tumours and guide future management.

Hepatic small vessel neoplasm case report: A surveillance conundrum.

INTRODUCTION: Hepatic small vessel neoplasm (HSVN) is a recently described vascular neoplasm of the liver that can mimic hepatic angiosarcoma (AS) because of its infiltrative nature but is considered benign or, at most, low-grade. HSVN appears to demonstrate a benign clinical course with no reported recurrences or metastatic disease, although its long-term malignant potential is uncertain. CASE PRESENTATION: We present a 57-year-old man with an incidentally growing segment VII lesion that displayed features concerning for a neoplasm. He underwent a posterior sectionectomy and final histopathology confirmed a 27 mm HSVN. As the long-term malignant potential of HSVN is uncertain, he will be followed up with serial MRI scans over the next 5 years. DISCUSSION: HSVN is a recently described entity, it is uncertain what the long-term malignant potential of HSVN can be. Reported cases have not shown any evidence of disease progression. CONCLUSION: There are no clear guidelines established on the duration of the follow-up of HSVN. More research needs to be done to determine further the natural history of these tumours and possible radiological criteria.

An International Group of Hepatopancreaticobiliary Surgeons Respond to the COVID-19 Pandemic.

An informal workgroup of 9 hepatopancreaticobiliary (HPB) surgeons from 6 different countries on 4 continents shifted the focus of their quarterly tumor board discussions to their responses to the current COVID-19 pandemic. Just as they had discussing HPB cases, they share their experiences and ideas in dealing with the outbreak that faced their hospitals and communities. Their efforts to improve care proved that professionalism in surgery, like the global pandemic, has no boundaries.

Early Experience with Laparoscopic Frey Procedure for Chronic Pancreatitis: a Case Series and Review of Literature.

The Frey procedure has been demonstrated to be an effective surgical technique to treat patients with painful large duct chronic pancreatitis. More commonly reported as an open procedure, we report our experience with a minimally invasive approach to the Frey procedure. Four consecutive patients underwent a laparoscopic Frey procedure at our institution from January 2012 to July 2015. We herein report our technique and describe short- and medium-term outcomes. The median age was 40 years old. The median duration of pancreatic pain prior to surgery was 12 years. Median operative time and intraoperative blood loss was 130 min (100-160 min) and 60 mL (50-100 mL), respectively. The median length of stay was 7 days (3-40 days) and median follow-up was 26 months (12-30 months). There was one major postoperative complication requiring reoperation. Within 6 months, in all four patients, frequency of pain and analgesic requirement reduced significantly. Two patients appeared to have resolution of pancreatic exocrine insufficiency. The Frey procedure is possible laparoscopically with acceptable short- and medium-term outcomes in well-selected patients.

Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe.

BACKGROUND: According to the Tokyo Guidelines, recommendation on management of moderate and severe cholecystitis are cholecystostomy in severe cases and either cholecystostomy or emergency cholecystectomy in moderate cases depending on surgical experience. The rationale for this is that percutaneous cholecystostomy is a short procedure while laparoscopic cholecystectomy may be associated with a larger physiological insult. The aim of this study was to determine the safety and efficacy of cholecystectomy in moderate and severe acute calculous cholecystitis (ACC) at our institution. METHODS: A retrospective review of patients presenting to Westmead Hospital with ACC between 2011 and 2012 was performed. Patients were classified according to the Tokyo Guidelines and only grade II and grade III patients were included. Clinical and complication details were recorded from the clinical notes. RESULTS: Of the 84 patients, 60 had grade II and 24 had grade III ACC. The mean age was 52 years and 59% were female. In both groups, index cholecystectomy was performed in 88% of patients. None of the grade II ACC patients and three (12%) of grade III ACC underwent cholecystostomy. Length of stay (5 versus 12, P < 0.001) and conversion rate (2% versus 27%, P = 0.006) was higher in the grade III group. There were no deaths in patient who underwent surgery in either group. Severe complications were not significantly different (2% versus 9%, P = 0.219). CONCLUSION: Index cholecystectomy is feasible with low morbidity and no mortality even in severe ACC. Emergency cholecystectomy in the setting of severe cholecystitis appear to be safe and technically feasible option.

Prevention of pelvic sepsis in major open pelviperineal injury.

Compound pelvic fractures are deemed to be one of the most severe orthopaedic injuries with an extremely high morbidity and mortality. After the initial resuscitation phase the prevention of pelvic sepsis is one of the main treatment goals for patients with an open pelvic fracture. If there is a suspicion of a rectal injury or if the wounds are in the perineal area, The Princess Alexandra Hospital's management plan includes early faecal diversion combined with vigorous soft tissue debridement, VAC(®) therapy and (if indicated) external fixation of the pelvic fracture. We present our flowchart for the treatment of trauma patients with compound pelvic fractures illustrated by a case report describing a 32 year old patient who sustained an open pelvic ring injury in a workplace accident. The aim of this paper is to underline the importance of a safe, straightforward approach to compound pelvic fractures.