Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Characterization of Acidosis in Trauma Patient.

BACKGROUND: Recent data suggest that acidosis alone is not a good predictor of mortality in trauma patients. Little data are currently available regarding factors associated with survival in trauma patients presenting with acidosis. AIMS: The aims were to characterize the outcomes of trauma patients presenting with acidosis and to identify modifiable risk factors associated with mortality in these patients. SETTINGS AND DESIGN: This is a retrospective observational study of University of Arkansas for Medical Sciences (UAMS) trauma patients between November 23, 2013, and May 21, 2017. METHODS: Data were collected from the UAMS trauma registry. The primary outcome was hospital mortality. Analyses were performed using t-test and Pearson's Chi-squared test. Simple and multiple logistic regressions were performed to determine crude and adjusted odds ratios. RESULTS: There were 532 patients identified and 64.7% were acidotic (pH < 7.35) on presentation: 75.9% pH 7.2-7.35; 18.5% pH 7.0-7.2; and 5.6% pH ≤ 7.0. The total hospital mortality was 23.7%. Nonsurvivors were older and more acidotic, with a base deficit >-8, Glasgow Coma Scale (GCS) ≤ 8, systolic blood pressure ≤ 90, International Normalized Ratio (INR) >1.6, and Injury Severity Score (ISS) >15. Mortality was significantly higher with a pH ≤ 7.2 but mortality with a pH 7.2-7.35 was comparable to pH > 7.35. In the adjusted model, pH ≤ 7.0, pH 7.0-7.2, INR > 1.6, GCS ≤ 8, and ISS > 15 were associated with increased mortality. For patients with a pH ≤ 7.2, only INR was associated with increase in mortality. CONCLUSIONS: A pH ≤ 7.2 is associated with increased mortality. For patients in this range, only the presence of coagulopathy is associated with increased mortality. A pH > 7.2 may be an appropriate treatment goal for acidosis. Further work is needed to identify and target potentially modifiable factors in patients with acidosis such as coagulopathy.

Hemorrhage-Control Training in Medical Education.

OBJECTIVES: To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students. METHODS: After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student's survey responses. A knowledge quiz was completed following the training. RESULTS: Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students' perceptions of the importance of this training for physicians and other allied health professionals. CONCLUSION: Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students' comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.

ROTEM as a Predictor of Mortality in Patients With Severe Trauma.

BACKGROUND: Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15. METHODS: We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality. RESULTS: The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not. CONCLUSIONS: A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Is It Safe to Fly Patients with Penetrating Trauma in a Rural State?

BACKGROUND: There is limited data pertaining to the triage and transportation of patients with penetrating trauma in rural states. Large urban trauma centers have found rapid transport to be beneficial even when done by nonemergency medical staff. However, there is limited application to a rural state with only a single level 1 trauma center. MATERIALS AND METHODS: This a retrospective observational study of 854 trauma patients transported by helicopter emergency services between 2009 and 2015 to the state's only level 1 trauma center. RESULTS: After excluding patients with other injuries or lack of data, 854 patients underwent final analysis. Compared with penetrating trauma, blunt trauma had a significantly different chance of survival (92.0% versus 81.2%, P = 0.002) and a significantly different injury severity score (17 ± 12 versus 12 ± 9, P = 0.002). After controlling for blunt injuries, age, gender, injury severity score, tachycardia, tachypnea, hypotension, glasgow coma scale, and dispatch to hospital arrival time in multivariate analysis, blunt trauma had higher odds of survival than penetrating trauma (OR, 5.97; 95% CI, 2.52-14.12; P = <0.001 = 1). Gender, tachycardia, tachypnea, and dispatch to arrival time did not impact a patient's likelihood of survival. CONCLUSIONS: Penetrating trauma has a higher mortality when compared with blunt trauma in Helicopter Emergency Services transported patients in a rural state. Perhaps a new algorithm in the management of penetrating trauma would include hemorrhage control at a locoregional hospital before definitive care. Further study is required to understand the exact variables that lead to a higher mortality in penetrating trauma in a rural state.

Right external iliac artery thrombus following the use of resuscitative endovascular balloon occlusion of the aorta for placenta accreta.

A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

Morning report decreases length of stay in trauma patients.

BACKGROUND: Modern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center. METHODS: The University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2. RESULTS: A total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients. DISCUSSION: This study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services. LEVEL OF EVIDENCE: Level 4, Care Management.

Dilated cardiomyopathy secondary to acute pancreatitis caused by hypertriglyceridemia.

A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis.

Severe acute gallstone pancreatitis with diffuse hemorrhagic gastritis.

A 67-year-old male presented with acute pancreatitis secondary to gallstones, also known as acute biliary pancreatitis, and subsequently developed gastric outlet obstruction and was transferred to our hospital. A gastro-jejunal feeding tube was placed and an open cholecystectomy was performed. The patient had a pancreatic drain placed for interval increase in pancreatic necrosis and then nearly exsanguinated from gastroduodenal artery pseudoaneurysm bleed. This was managed by coiling the gastroduodenal artery. The patient underwent a pancreatic necrosectomy with malencot drain placement and developed a post-operative upper gastrointestinal bleeding. An EGD showed diffuse gastritis, but no varices. And 18 days later the patient rebled, with the same diffuse gastritis. After further complications the patient elected to receive palliative care at a hospice facility. We are presenting this unusual case of diffuse, hemorrhagic gastritis after acute necrotizing pancreatitis.

The importance of surgeon-reviewed computed tomography for incisional hernia detection: a prospective study.

Patients with incisional hernias or abdominal pain are frequently referred with abdominal computed tomography (CT) scans. The purpose of this study was to determine the sensitivity and specificity of a CT radiology report for the detection of incisional hernias. General surgery patients with a history of an abdominal operation and a recent viewable abdominal CT scan were enrolled prospectively. Patients with a stoma, fistula, or soft tissue infection were excluded. The results of the radiology reports were compared with blinded, surgeon-interpreted CT for each patient. Testing characteristics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. One hundred eighty-one patients were enrolled with a mean age of 54 years. Sixty-eight per cent were women. Hernia prevalence was 55 per cent, and mean hernia width was 5.2 cm. The radiology report had a sensitivity and specificity of 79 per cent and 94 per cent, respectively, for hernia diagnosis. The PPV and NPV were 94 and 79 per cent, respectively. Reliance on the CT report alone underestimates the presence of incisional hernia. Referring physicians should not use CT as a screening modality for detection of hernias. Referral to a surgeon for evaluation before imaging may provide more accurate diagnosis and potentially decrease the cost of caring for this population.

Comparative Evaluation of Dynamic Abdominal Sonography for Hernia and Computed Tomography for Characterization of Incisional Hernia.

IMPORTANCE: Previous work has demonstrated that dynamic abdominal sonography for hernia (DASH) is accurate for the diagnosis of incisional hernia. The usefulness of DASH for characterization of incisional hernia is unknown. OBJECTIVE: To determine whether DASH can be objectively used to characterize incisional hernias by measurement of mean surface area (MSA). DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted. A total of 109 adults with incisional hernia were enrolled between July 1, 2010, and March 1, 2012. Patients with a stoma, fistula, or soft-tissue infection were excluded. INTERVENTIONS: DASH was performed by a surgeon to determine the maximal transverse and craniocaudal dimensions of the incisional hernia. A separate surgeon, blinded to the DASH results, performed the same measurements using computed tomography (CT). MAIN OUTCOMES AND MEASURES: The MSA was calculated, and the difference in MSA by DASH and CT was compared using the Wilcoxon signed rank test. Subset analysis was performed with patients stratified into nonobese, obese, and morbidly obese groups. We hypothesized that there was no significant difference between MSA as measured by DASH compared with CT. RESULTS: A total of 109 patients were enrolled (mean age, 56 years; mean body mass index, 32.2 [calculated as weight in kilograms divided by height in meters squared]; and 67.0% women). The mean (SD) MSA measurements were similar between the modalities: DASH, 41.8 (67.5) cm2 and CT, 44.6 (78.4) cm2 (P = .82). The MSA measurements determined by DASH and CT were also similar for all groups when stratified by body mass index. There were 15 patients who had a hernia 10 cm or larger in transverse dimension. The mean body mass index of this group was 39.2, and the MSA measurements by DASH and CT were similar (P = .26). CONCLUSIONS AND RELEVANCE: DASH can be used to objectively characterize hernias by MSA, with accuracy demonstrated in the obese population and in patients whose hernias were very large (≥10 cm in diameter). DASH offers the advantages of real-time imaging and no ionizing radiation and may obviate the need for the patient to schedule additional imaging appointments.

Prospective evaluation of surgeon physical examination for detection of incisional hernias.

BACKGROUND: Surgeon physical examination is often used to monitor for hernia recurrence in clinical and research settings, despite a lack of information on its effectiveness. This study aims to compare surgeon-reviewed CT with surgeon physical examination for the detection of incisional hernia. STUDY DESIGN: General surgery patients with an earlier abdominal operation and a recent viewable CT scan of the abdomen and pelvis were enrolled prospectively. Patients with a stoma, fistula, or soft-tissue infection were excluded. Surgeon-reviewed CT was treated as the gold standard. Patients were stratified by body mass index into nonobese (body mass index <30) and obese groups. Testing characteristics and real-world performance, including positive predictive value and negative predictive value, were calculated. RESULTS: One hundred and eighty-one patients (mean age 54 years, 68% female) were enrolled. Hernia prevalence was 55%. Mean area of hernias was 44.6 cm(2). Surgeon physical examination had a low sensitivity (77%) and negative predictive value (77%). This difference was more pronounced in obese patients, with sensitivity of 73% and negative predictive value 69%. CONCLUSIONS: Surgeon physical examination is inferior to CT for detection of incisional hernia, and fails to detect approximately 23% of hernias. In obese patients, 31% of hernias are missed by surgeon physical examination. This has important implications for clinical follow-up and design of studies evaluating hernia recurrence, as ascertainment of this result must be reliable and accurate.

Disease-based mortality after percutaneous endoscopic gastrostomy: utility of the enterprise data warehouse.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) remains a mainstay of enteral access. Thirty-day mortality for PEG has ranged from 16 to 43 %. This study aims to discern patient groups that demonstrate limited survival after PEG placement. The Enterprise Data Warehouse (EDW) concept allows an efficient means of integrating administrative, clinical, and quality-of-life data. On the basis of this concept, we developed the Vanderbilt Procedural Outcomes Database (VPOD) and analyzed these data for evaluation of post-PEG mortality over time. METHODS: Patients were identified using the VPOD from 2008 to 2010 and followed for 1 year after the procedure. Patients were categorized according to common clinical groups for PEG placement: stroke/CNS tumors, neuromuscular disorders, head and neck cancers, other malignancies, trauma, cerebral palsy, gastroparesis, or other indications for PEG. All-cause mortality at 30, 60, 90, 180, and 360 days was determined by linking VPOD information with the Social Security Death Index. Chi-square analysis was used to determine significance across groups. RESULTS: Nine hundred fifty-three patients underwent PEG placement during the study period. Mortality over time (30-, 60-, 90-, 180-, and 360-day mortality) was greatest for patients with malignancies other than head and neck cancer (29, 45, 57, 66, and 72 %) and least for cerebral palsy or patients with gastroparesis (7 % at all time points). Patients with neuromuscular disorders had a similar mortality curve as head and neck cancer patients. Stroke/CNS tumor patients and patients with other indications had the second highest mortality, while trauma patients had low mortality. CONCLUSIONS: PEG mortality was much higher in patients with malignancies other than head and neck cancer compared to previously published rates. PEG should be used with great caution in this and other high-risk patient groups. This study demonstrates the power of an EDW-based database to evaluate large numbers of patients with clinically meaningful results.

The chosen few: disproportionate resource use in ventral hernia repair.

The objectives of this study were to determine if disproportionately small numbers of patients use more resources for ventral hernia repair (VHR) and to identify factors associated with this group. Patients undergoing VHR were identified using national 2009 Healthcare Cost and Utilization Project data. Mean total hospital charges (THCs) were calculated and patients were divided into high charges (HC, greater than 50% mean THC) and low charges (LC, 50% or less mean THC) groups. Multivariate analysis was used to identify factors associated with the HC group. We estimated 181,000 hospitalizations for VHR in 2009 with mean THC of $54,000. Fifteen per cent of patients comprised the HC group with 85 per cent in the LC group. The HC group had higher THC ($173,000 vs $32,000; P < 0.05), increased mean length of stay (16.0 vs 4.1 days, P < 0.05), and higher mortality (6.3 vs 0.6%, P < 0.05). Risk factors for HC included congestive heart failure (odds ratio [OR], 2.2; 95% confidence interval [CI], 2.0 to 2.5), chronic lung disease (OR, 1.3; 95% CI, 1.2 to 1.4), Asian race (OR, 2.5; 95% CI, 1.7 to 3.7), nonelective operation (OR, 1.9; 95% CI, 1.6 to 2.3), and male gender (OR, 1.2; 95% CI, 1.1 to 1.3). For inpatient VHR, a remarkably small proportion of patients use disproportionately high hospital resources. The identified risk factors can help surgeons predict patients who are likely to consume large amounts of resources.

Comparative effectiveness of dynamic abdominal sonography for hernia vs computed tomography in the diagnosis of incisional hernia.

BACKGROUND: Diagnosis and characterization of incisional hernia are often established by CT, which incurs radiation exposure and substantial cost in clinical practice. The purpose of this study was to determine the comparative effectiveness of surgeon-performed Dynamic Abdominal Sonography for Hernia (DASH) vs CT for incisional hernia evaluation. STUDY DESIGN: Patients with previous abdominal operations and recent CT imaging were enrolled prospectively; patients with stomas, fistula, or soft tissue infection were excluded. In the clinic setting, DASH was performed with prerequisite training of the American College of Surgeons Ultrasound for Surgeons Basic Course. Clinical evidence of hernia, results of DASH examination, and radiologist documentation of incisional hernia were compared with the gold standard of surgeon-interpreted CT. Testing characteristics of sensitivity and specificity were compared and predictive values were calculated. Inter-rater reliability was performed by comparing DASH results in a subgroup of patients with 3 different evaluators. RESULTS: There were 181 patients enrolled, with a mean age of 54 years, and 68% were women. In patients in whom hernias were identified, the mean hernia size was 44.6 cm(2) (range 0.2 to 468.3 cm(2)). The DASH examination showed high sensitivity (98%) and specificity (88%). Hernia prevalence was 55% in this population, resulting in positive and negative predictive values of 91% and 97%, respectively. Four patients had clinically detectable hernias that were not seen on CT but were discovered with DASH. Inter-rater reliability for DASH was high, with an observed intraclass correlation coefficient of 0.79. CONCLUSIONS: The DASH examination is an accurate alternative to CT scan for diagnosing abdominal wall hernias, with additional benefits of no radiation exposure and instant bedside interpretation. The use of DASH to detect hernia recurrence can greatly facilitate long-term follow-up of hernia patients.

Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis.

BACKGROUND: After surviving an episode of acute necrotizing pancreatitis (ANP), a variety of late sequelae develop and require nonoperative or operative interventions. Persistent pancreatic fistula, fluid collections, recurrent pancreatitis, sepsis, pain, and intolerance of po intake are seen. STUDY DESIGN: We have maintained records for all patients hospitalized from 1993 through 2010 with a diagnosis of ANP. Once discharged from hospital, patients were managed with routine clinic follow-up at close intervals and later at 6-month intervals. Using ERCP or magnetic resonance cholangiopancreatography, all patients' pancreatic ducts were classified as type I (normal), type II (stricture), or type III (disconnected). Patients were monitored for the complications mentioned. Operations performed >8 weeks after the initial episode of ANP were defined as late and evaluated for operative mortality, morbidity, success in resolving symptoms/collections, and length of stay. RESULTS: One hundred and ninety-seven patients with ANP were included. Seventy-one late operations were performed (59 drainage procedures/12 resections). Operative mortality was 1%, morbidity was 19%, and mean length of stay was 6.3 ± 5.6 days. Poor po intake was seen in 80% of operated patients and total parenteral nutrition dependence in 42%. Duct type correlated with pancreatic debridement, persistent fluid collection/fistula, pain, po intake intolerance, and late operation. Late operation successfully resolved symptoms and/or fluid collections in 96%. Recurrent pancreatitis was improved in 87% and eliminated in 78%. CONCLUSIONS: Patients who require late operation after surviving an episode of ANP are more likely to have sustained ductal injuries and are likely to require operation for either pain or for inability to tolerate po intake. Operation can be performed safely with a low mortality.

Achalasia.

This article reviews the diagnosis and treatment of achalasia, a rare esophageal motility disorder characterized by absent peristalsis and failure of the lower esophageal sphincter (LES) to relax. Various treatment options including management with sublingual nitrates or calcium channel blockers, injection of the LES with botulism toxin, pneumatic dilation of the LES, and pneumatic dilation are discussed. Laparoscopic Heller myotomy is minimally invasive with incumbent low morbidity and mortality rates, and combined with a partial fundoplication is a durable, safe, and effective treatment option for patients with achalasia.