The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013.

INTRODUCTION: Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS: The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS: Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS: Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.

Repeat hepatic resection for colorectal liver metastases.

BACKGROUND: Some 75-80 per cent of patients undergoing liver resection for colorectal liver metastases develop intrahepatic recurrence. A significant number of these can be considered for repeat liver surgery. This study examined the outcomes of repeat liver resection for the treatment of recurrent colorectal metastases confined to the liver. METHODS: Patients who underwent repeat liver resection in a single tertiary referral hepatobiliary centre were identified from a database. Clinicopathological variables were analysed to assess factors predictive of survival. RESULTS: A total of 195 patients underwent repeat resection between 1993 and 2010. Median age was 63 years, and the median interval between first and repeat resection was 13·8 months. Thirty-three patients (16·9 per cent) underwent completion hemihepatectomy or extended hemihepatectomy and the remainder had non-anatomical or segmental resection. The 30-day mortality rate was 1·5 per cent, and the overall 30-day morbidity rate was 20·0 per cent. Overall 1-, 3- and 5-year survival rates were 91·2, 44·3 and 29·4 per cent respectively. Tumour size 5 cm or greater was the only independent predictor of overall survival (relative risk 1·71, 95 per cent confidence interval 1·08 to 2·70; P = 0·021). Neoadjuvant chemotherapy before resection, perioperative blood transfusion, bilobar disease, R1 resection margin and multiple metastases were among factors that did not significantly influence survival. CONCLUSION: Repeat hepatic resection remains the only curative option for patients presenting with recurrent colorectal liver metastases.

The success of routine MRSA screening in vascular surgery: a nine year review.

AIM: Methicillin resistant Staphylococcus aureus (MRSA) infection in vascular patients is associated with increased morbidity and mortality. We investigated whether routine MRSA screening reduced complications related to MRSA infection. METHODS: Data was analysed for all MRSA positive (+ve) vascular patients admitted before (1996-2000) and after (2001-2004) routine MRSA screening was introduced. Outcome measures compared included wound infection, major limb amputation and mortality rates. RESULTS: There were 92 and 188 MRSA +ve patients in the pre- and postscreening periods, respectively. After the introduction of MRSA screening, MRSA wound infection in MRSA +ve elective admissions was significantly reduced from 55.6% (20/36) to 22.4% (15/67), (P=0.002, chi2 test); amputations were reduced from 27.8% (10/36) to 9% (6/67), P value 0.026, and mortality from 16.7% (6/36) to 9% (6/67), P value >0.05. In MRSA +ve emergency admissions wound infection was significantly reduced from 62.5% (35/56) to 43.8% (53/121), P value 0.042, amputations from 50% (28/56) to 38.8% (47/121), P value 0.26, and mortality from 25% (14/56) to 12.4% (15/121), P value 0.067. CONCLUSIONS: While the incidence of MRSA infection continues to rise, we have successfully demonstrated that MRSA screening identifies patients at risk of serious complications and is associated with a reduction in these complications following both elective and emergency surgery. Routine screening of all vascular admissions should be part of the strategy to combat MRSA infection.

Ventricular rupture secondary to cardiac metastasis of transitional cell carcinoma of the bladder.

We report a patient with transitional cell carcinoma of the bladder who had metastatic nodules in the myocardium of the left ventricle and tumour emboli in the left circumflex artery which caused myocardial infarction with ventricular rupture and haemopericardium. Cardiac metastasis of transitional cell carcinoma of the bladder is discussed and the literature reviewed.

Is it possible to predict outcome in MRSA positive patients undergoing arterial reconstruction?

AIM: There is an increasing incidence of methicillin resistant Staphylococcus aureus (MRSA) following vascular surgery, which is associated with poor outcome. The risk factors and timing for MRSA acquisition have been established. We attempt to establish predictors of outcome in MRSA positive patients undergoing arterial reconstruction. METHODS: Eighty-five MRSA positive patients who underwent arterial surgery were grouped according to outcome: good outcome group (successful revascularisation) or poor outcome group (major limb amputation or death). Seven variables were compared: age, gender, renal function, co-morbidity, positive swab site, incision site and second revascularisation surgery. RESULTS: Increased MRSA incidence from 1.1% to 4.6% of total admissions was highlighted over a 6 year period. When good (n=40) and poor (n=45) outcome groups were compared, no statistically significant differences were identified for the variables listed above, but a second revascularisation operation was 3 times more likely to be associated with poor outcome (P=0.09). Categorising gender and age groups suggests that male gender and age over 75 years was more likely to be associated with poor outcome (odds ratio 0.77). The results also suggest that patients having surgery involving a groin incision do worse than those who do not. One year survival of MRSA positive patients who had successful revascularisation was 90% and a significant number had MRSA eradicated. CONCLUSIONS: Although this study was unable to identify statistically significant predictors of outcome in patients with MRSA undergoing arterial reconstruction, almost half had a positive outcome. An aggressive detection and eradication policy is clearly indicated.