Study of the early management of acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common acute surgical presentation with evidence-based guidelines for early management. The aim of this study was to assess the compliance to the published guidelines in patients presenting with AP in Western Sydney. METHODS: A retrospective case note audit was conducted for all patients with a confirmed diagnosis of AP from 2008 to 2011 in Western Sydney. RESULTS: There were 932 patients. The mortality was low for mild (0.7%) and severe (1.2%) AP. There was an under-utilization of ultrasound (U/S) with 239 (25.6%) patients not having a U/S. There was an over-utilization of early (within 72 h) computed tomography scanning for diagnosis (31.1%), assessment of severity (16.1%) and assessment for the presence of complications (7.3%). Inappropriate prophylactic antibiotic usage occurred in 15.3% patients. Of 373 cases of gallstone pancreatitis, only 231 (69.1%) had a cholecystectomy within 4 weeks of presentation. There was an under-utilization of early endoscopic retrograde cholangiopancreatography for associated cholangitis (12.5%). Only 16 (18.8%) patients with severe pancreatitis received enteric feeding. In patients with pancreatic necrosis, 50% had invasive intervention delayed beyond 4 weeks and 69% had minimally invasive procedures performed prior to necrosectomy. Patients having a minimally invasive procedure initially showed an improvement in mortality compared with those who had primary necrosectomy (0 versus 40%, P = 0.025). CONCLUSIONS: Although morbidity and mortality were acceptable, there was a failure to comply with evidence-based guidelines for the early management of pancreatitis. The results support for the development and auditing of protocols for the early assessment and treatment of AP in all hospitals.

Controlling hemorrhage in exsanguinating pelvic fractures: Utility of extraperitoneal pelvic packing as a damage control procedure.

INTRODUCTION: Exsanguinating pelvic fractures are still associated with a significant mortality rate of 28-60%. Extraperitoneal pelvic packing (EPP) has been proposed as an optimal method of early haemorrhage control. The aim of this study was to determine the effect of EPP compared with angioembolization as a primary intervention for patients with exsanguinating pelvic fracture. METHOD: A prospective observational trial was performed at Westmead Hospital between September 2011 and May 2014. Adult patients with exsanguinating pelvic fracture were allocated into one of two treatment groups determined by the primary/initial haemorrhage control technique: 1. EPP followed by angioembolization or 2. Angioembolization alone. The intervention was determined by the on-call surgeon's proficiency with EPP. Demographic, clinical and laboratory data were collected. Univariate analysis of the two groups was performed with Student's t-test, Mann-Whitney-U test and Fisher's exact test. RESULTS: 24 exsanguinating pelvic fracture cases were included. 14 underwent EPP while 10 underwent angioembolization as the primary intervention. Although not statistically significant, the EPP group was more severely injured (Injury Severity Score 32 vs. 23), more acidotic (base deficit 7.9 vs. 6.2), and more hypotensive (Systolic Blood Pressure 74.2 vs. 84.3). Despite these differences, mortality was reduced (7.1% vs. 30%, not significant). Time to EPP compared with angioembolization was reduced (67.6 vs. 130.2 minutes, P = 0.017). Pre-angioembolization transfusion requirement was also reduced with EPP (0.032 vs. 0.052 units/min, P = 0.04). Arterial injury was found in 51% of the EPP group. There were no significant differences in complication rates between the groups. CONCLUSION: EPP appears to be a safe and efficient technique for primary haemorrhage control in exsanguinating pelvic fractures. Given the high rate of associated arterial injury, EPP should be considered as the first part of a "damage control" approach for exsanguinating pelvic fractures.

Epidemiology, aetiology and outcomes of acute pancreatitis: A retrospective cohort study.

BACKGROUND: Acute pancreatitis is a common acute surgical presentation in Western Society. The causes and pattern of pancreatitis has not been previously documented for Western Sydney. As Western Sydney contains many areas of low socio-economic status with an expected high level of alcohol abuse, it was hypothesised that alcoholic pancreatitis would be more prevalent in this population. The aims of this study were to determine the epidemiology, aetiology and outcomes of acute pancreatitis. METHODS: A retrospective analysis of patients presenting with acute pancreatitis to four tertiary hospitals over a four-year period was undertaken. RESULTS: 932 patients presented with acute pancreatitis with a median age of 50 years (range 16-95); 470 (50.4%) were female. Almost half had gallstones (40%), 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP. 69 (7.4%) of patients were admitted to ICU/HDU, with a median length of stay in ICU was 6 days (range 1-106). 85 (11.1%) patients had severe pancreatitis (score ≥ 3). Mortality in this study was 1% (9). CONCLUSION: The majority of patients with acute pancreatitis in Western Sydney present with mild disease and have a low risk of morbidity or mortality. The ratio of gallstone to alcohol aetiology was 2:1. Idiopathic pancreatitis is responsible for more cases than expected.