Extracorporeal shock wave lithotripsy for pancreatic duct stones in patients with chronic pancreatitis: Are we underutilizing a new technology?

The progressive inflammatory nature of chronic pancreatitis and its sparse therapeutic toolbox remain obstacles in offering patients durable solutions for their symptoms. Obstruction of the main pancreatic duct by either strictures or stones represents a scenario worthy of therapeutic focus, as nearly all patients with pancreatitis eventually have intraductal stones. A more recent option for removal of main duct stones is extracorporeal shock wave lithotripsy (ESWL). In an effort to explore the role of ESWL in a Canadian setting, we evaluated our initial experience over an 8-year period (2011-2019).

Is the Pringle manoeuvre becoming a lost art? Contemporary use for both severe liver trauma with ongoing hemorrhage and elective partial hepatectomy.

The Pringle manoeuvre (vascular inflow occlusion) has been a mainstay technique in trauma surgery and hepato-pancreato-biliary surgery since it was first described in the early 1900s. We sought to determine how frequently the manoeuvre is used today for both elective and emergent cases in these disciplines. To reflect on its evolution, we evaluated the Pringle manoeuvre over a recent 10-year period (2010-2020). We found it is used less frequently owing to more frequent nonoperative management and more advanced elective hepatic resection techniques. Continuing educational collaboration is critical to ensure continued insight into the impact of hepatic vascular inflow occlusion among trainees who observe this procedure less frequently.

Preoperative Single-dose Methylprednisolone Prevents Surgical Site Infections After Major Liver Resection: A Randomized Controlled Trial.

OBJECTIVE: The primary aim of this study was to evaluate the efficacy of a single preoperative dose of methylprednisolone for preventing postoperative complications after major liver resections. SUMMARY BACKGROUND DATA: Hepatic resections are associated with a significant acute systemic inflammatory response. This effect subsequently correlates with postoperative morbidity, mortality, and length of recovery. Multiple small trials have proposed that the administration of glucocorticoids may modulate this effect. METHODS: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients undergoing elective major hepatic resection (≥3 segments) at a quaternary care institution were included (2013-2019). Patients were randomly assigned to receive a single preoperative 500 mg dose of methylprednisolone versus placebo. The main outcome measure was postoperative complications after liver resection, within 90 days of the index operation. Standard statistical methodology was employed (P < 0.05 = significant). RESULTS: A total of 151 patients who underwent a major hepatic resection were randomized (mean age = 62.8 years; 57% male; body-mass-index = 27.9). No significant differences were identified between the intervention and control groups (age, sex, body-mass-index, preoperative comorbidities, hepatic function, ASA class, portal vein embolization rate) (P > 0.05). Underlying hepatic diagnoses included colorectal liver metastases (69%), hepatocellular carcinoma (18%), noncolorectal liver metastases (7%), and intrahepatic cholangiocarcinoma (6%). There was a significant reduction in the overall incidence of postoperative complications in the methylprednisolone group (31.2% vs 47.3%; P = 0.042). Patients in the glucocorticoid group also displayed less frequent organ space surgical site infections (6.5% vs 17.6%; P = 0.036), as well as a shorter length of hospital stay (8.9 vs 12.5 days; P = 0.015). Postoperative serum bilirubin and prothrombin timeinternational normalized ratio (PT-INR) levels were also lower in the steroid group (P = 0.03 and 0.04, respectively). Multivariate analysis did not identify any additional significant modifying factor relationships (estimated blood loss, duration of surgery, hepatic vascular occlusion (rate or duration), portal vein embolization, drain use, etc) (P > 0.05). CONCLUSIONS: A single preoperative dose of methylprednisolone significantly reduces the length of hospital stay, postoperative serum bilirubin, and PT-INR, as well as infectious and overall complications following major hepatectomy.

The art and craft of biliary T-tube Use.

INTRODUCTION: Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management. METHODS: Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage. RESULTS: Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting. CONCLUSIONS: Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use. LEVEL OF EVIDENCE: Expert opinion, level V.

Adverse Outcomes After Bile Spillage in Incidental Gallbladder Cancers: A Population-based Study.

OBJECTIVE: To determine the effect of bile spillage during cholecystectomy on oncological outcomes in incidental gallbladder cancers. BACKGROUND: Gallbladder cancer (GBC) is rare, but lethal. Achieving complete resection offers the best chance of survival. About 30% of GBCs are discovered incidentally after cholecystectomy for benign pathology. There is an anecdotal association between peritoneal dissemination and bile spillage during the index cholecystectomy. However, no population-based studies are available that measure the consequences of bile spillage on patient outcomes. METHODS: We conducted a retrospective cohort comparison of patients with incidental GBC. All cholecystectomies and cases of GBC in Alberta, Canada, from 2001 to 2015, were identified. GBCs discovered incidentally were included. Operative events leading to bile spillage were reviewed. Patient outcomes were compared between cases of bile spillage versus no contamination. RESULTS: In all, 115,484 cholecystectomies were performed, and a detailed analysis was possible in 82 incidental GBC cases. In 55 cases (67%), there was bile spillage during the index cholecystectomy. Peritoneal carcinomatosis occurred more frequently in those with bile spillage (24% vs 4%; P = 0.0287). Patients with bile spillage were less likely to undergo a radical re-resection (25% vs 56%; P = 0.0131) and were less likely to achieve an R0 resection margin [odds ratio 0.19, 95% confidence interval (CI) 0.06-0.55]. On Cox regression modeling, bile spillage was an independent predictor of shorter disease-free survival (hazard ratio 1.99, 95% CI 1.07-3.67). CONCLUSION: For incidentally discovered GBC, bile spillage at the time of index cholecystectomy has measureable adverse consequences on patient outcomes. Early involvement of a hepatobiliary specialist is recommended where concerning features for GBC exist.

Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis.

OBJECTIVE: The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND: WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS: A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant. RESULTS: One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%). CONCLUSION: Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

Effect of proximity to specialty care on outcomes for biliary cancers: a population-based retrospective cohort study.

BACKGROUND: The management of biliary cancers is complex and requires a multidisciplinary approach. Because it is unknown how access to specialty care affects resource use and survival in patients with biliary cancer, we conducted a population-based study to understand the needs of these patients and the relation of geography to care delivery and clinical outcomes for biliary cancer in Alberta. METHODS: All patients with biliary cancer diagnosed in Alberta from Sept. 1, 2001, to Dec. 31, 2015 were included in this population-based retrospective cohort study. Data were extracted from administrative databases and the 2011 Canadian census. Driving time and types of medical services were tracked throughout the patients' clinical course. We categorized proximity to specialty care according to driving time to the nearest specialist. The primary outcome was overall survival. We conducted Cox proportional hazard regression to evaluate the effects of driving time on overall survival and multivariate logistic regression to evaluate the effect of driving time on treatment types and stage at diagnosis. RESULTS: We identified 1610 patients with biliary cancer; they accounted for 117 381 medical encounters. Patients living 120 minutes or more from the nearest hepatobiliary surgeon and from the nearest cancer centre had significantly decreased survival (hazard ratio [and 95% confidence interval (CI)] 1.27 [1.17-1.37]) and 1.27 [1.14-1.41], respectively). Location of residence was not associated with advanced stage or probability of undergoing surgery or a biliary drainage procedure. Patients who lived 120 minutes or more from a cancer centre were less likely than those who lived less than 120 minutes away to receive chemotherapy (odds ratio 0.51, 95% CI 0.29-0.88). Subgroup analysis showed that the effect of travel time was especially pronounced among those who received only best supportive care and those who had biliary drains. INTERPRETATION: Geography and accessibility to specialty care affected survival in patients with biliary cancer. Further study is required to understand how patients with biliary drains and those receiving best supportive care are affected by proximity to specialty care. This will aid in the identification of strategies to provide improved care for this subgroup who are particularly affected by geography.

Host phenotype is associated with reduced survival independent of tumour biology in patients with colorectal liver metastases.

BACKGROUND: Most prognostic scoring systems for colorectal liver metastases (CRLMs) account for factors related to tumour biology. Little is known about the effects of the host phenotype to the tumour. Our objective was to delineate the relationship of systemic inflammation and body composition features [i.e. low skeletal muscle mass (sarcopenia) and low visceral adipose tissue (VAT)], two well-described host phenotypes in cancer. METHODS: Clinical data and pre-operative blood samples were collected from 99 patients who underwent resection of CRLM. Pre-operative computed tomography scans were available for 97 patients; body composition was analysed at the L3 level, stratified for sex and age. Clinicopathological variables, serum C-reactive protein (CRP), and various body composition variables were evaluated. Overall survival was evaluated as a function of these same variables in multivariate Cox regression analysis. RESULTS: Skeletal muscle was significantly correlated with VAT (r = 0.46, P < 0.001). Of patients with sarcopenia, 35 (65%) also had low VAT. C-reactive protein was elevated (≥5 mg/mL) in 42 patients (43.3%). Elevated CRP was more common in patients with sarcopenia (73.8% vs. 51.1%, P = 0.029). The most significant prognostic factors were the coincidence of elevated CRP and adverse body composition features (sarcopenia and/or low VAT; hazard ratio 4.3, 95% confidence interval 1.5-13.0, P = 0.008), as well as Fong clinical prognostic score (hazard ratio 2.9, 95% confidence interval 1.5-5.5, P = 0.002). CONCLUSIONS: Body composition in patients with CRLM is not directly linked to the presence of systemic inflammation. However, when systemic inflammation coincides with sarcopenia and/or low VAT, prognosis is adversely affected, independent of the Fong clinical prognostic score.

Acute kidney injury following resection of hepatocellular carcinoma: prognostic value of the acute kidney injury network criteria

Background: Acute kidney injury (AKI) is associated with increased morbidity and mortality after liver resection. Patients with hepatocellular carcinoma (HCC) have a higher risk of AKI owing to the underlying association between hepatic and renal dysfunction. Use of the Acute Kidney Injury Network (AKIN) diagnostic criteria is recommended for patients with cirrhosis, but remains poorly studied following liver resection. We compared the prognostic value of the AKIN creatinine and urine output criteria in terms of postoperative outcomes following liver resection for HCC. Methods: All patients who underwent a liver resection for HCC from January 2010 to June 2016 were included. We used AKIN urine output and creatinine criteria to assess for AKI within 48 hours of surgery. Results: Eighty liver resections were performed during the study period. Cirrhosis was confirmed in 80%. Median hospital stay was 9 (interquartile range 7­12) days, and 30-day mortality was 2.5%. The incidence of AKI was higher based on the urine output than on the creatinine criterion (53.8% v. 20%), and was associated with prolonged hospitalization and 30-day postoperative mortality when defined by serum creatinine (hospital stay: 11.2 v. 20.1 d, p = 0.01; mortality: 12.5% v. 0%, p < 0.01), but not urine output (hospital stay: 15.6 v. 10 d, p = 0.05; mortality: 2.3% v. 2.7%, p > 0.99). Conclusion: The urine output criterion resulted in an overestimation of AKI and compromised the prognostic value of AKIN criteria. Revision may be required to account for the exacerbated physiologic postoperative reduction in urine output in patients with HCC.

L'insuffisance rénale aiguë (IRA) est associée à une morbidité et à une mortalité accrues après une résection hépatique. Les patients atteints d'un carcinome hépatocellulaire (CHC) sont exposés à un risque plus grand d'IRA en raison du lien sous-jacent entre l'insuffisance hépatique et l'insuffisance rénale. Les critères diagnostiques de l'Acute Kidney Injury Network (AKIN) sont recommandés chez les patients cirrhotiques, mais ils n'ont pas été bien étudiés dans les cas de résection hépatique. Nous avons comparé la valeur pronostique des critères de l'AKIN tels que la créatinine et le débit urinaire pour ce qui est des résultats postopératoires suite à une résection hépatique pour CHC. Méthodes: Tous les patients soumis à une résection hépatique pour CHC entre janvier 2010 et juin 2016 ont été inclus. Nous avons utilisé les critères de l'AKIN concernant le débit urinaire et la créatinine pour évaluer l'IRA dans les 48 heures suivant la chirurgie. Résultats: Quatre-vingt résections hépatiques ont été effectuées pendant la périodeVde l'étude. La cirrhose a été confirmée dans 80 % des cas. Le séjour hospitalierVmédian a duré 9 jours (intervalle interquartile 7­12 jours) et la mortalité à 30 jours a été de 2,5 %. L'incidence de l'IRA a été plus élevée selon le critère débit urinaire que selon le critère créatinine (53,8 % c. 20 %), et a été associée à un séjour plus long et à une mortalité à 30 jours plus élevée suite à l'intervention selon le critère créatinine sérique (séjour hospitalier : 11,2 c. 20,1 j, p = 0,01; mortalité : 12,5 % c. 0 %, p < 0,01), mais non selon le critère débit urinaire (séjour hospitalier : 15,6 c. 10 j, p = 0,05; mortalité : 2,3 % c. 2,7 %, p > 0,99).

Sarcopenia and myosteatosis are accompanied by distinct biological profiles in patients with pancreatic and periampullary adenocarcinomas.

INTRODUCTION: Pancreatic and periampullary adenocarcinomas are associated with abnormal body composition visible on CT scans, including low muscle mass (sarcopenia) and low muscle radiodensity due to fat infiltration in muscle (myosteatosis). The biological and clinical correlates to these features are poorly understood. METHODS: Clinical characteristics and outcomes were studied in 123 patients who underwent pancreaticoduodenectomy for pancreatic or non-pancreatic periampullary adenocarcinoma and who had available preoperative CT scans. In a subgroup of patients with pancreatic cancer (n = 29), rectus abdominus muscle mRNA expression was determined by cDNA microarray and in another subgroup (n = 29) 1H-NMR spectroscopy and gas chromatography-mass spectrometry were used to characterize the serum metabolome. RESULTS: Muscle mass and radiodensity were not significantly correlated. Distinct groups were identified: sarcopenia (40.7%), myosteatosis (25.2%), both (11.4%). Fat distribution differed in these groups; sarcopenia associated with lower subcutaneous adipose tissue (P<0.0001) and myosteatosis associated with greater visceral adipose tissue (P<0.0001). Sarcopenia, myosteatosis and their combined presence associated with shorter survival, Log Rank P = 0.005, P = 0.06, and P = 0.002, respectively. In muscle, transcriptomic analysis suggested increased inflammation and decreased growth in sarcopenia and disrupted oxidative phosphorylation and lipid accumulation in myosteatosis. In the circulating metabolome, metabolites consistent with muscle catabolism associated with sarcopenia. Metabolites consistent with disordered carbohydrate metabolism were identified in both sarcopenia and myosteatosis. DISCUSSION: Muscle phenotypes differ clinically and biologically. Because these muscle phenotypes are linked to poor survival, it will be imperative to delineate their pathophysiologic mechanisms, including whether they are driven by variable tumor biology or host response.

Efficacy of a Dual-ring Wound Protector for Prevention of Surgical Site Infections After Pancreaticoduodenectomy in Patients With Intrabiliary Stents: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the efficacy of a dual-ring wound protector for preventing incisional surgical site infection (SSI) among patients with preoperative biliary stents undergoing pancreaticoduodenectomy (PD). METHODS AND ANALYSIS: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients with a biliary stent undergoing elective PD at 2 tertiary care institutions were included (February 2013 to May 2016). Patients were randomly assigned to receive a surgical dual-ring wound protector or no wound protector, and also the current standard of care. The main outcome measure was incisional SSI, as defined by the Centers for Disease Control and Prevention criteria, within 30 days of the index operation. RESULTS: A total of 107 patients were recruited (mean age 67.2 years; standard deviation 12.9; 65% male). No significant differences were identified between the intervention and control groups (age, sex, body mass index, preoperative comorbidities, American Society of Anesthesiologists class, prestent cholangitis). There was a significant reduction in the incidence of incisional SSI in the wound protector group (21.1% vs 44.0%; relative risk reduction 52%; P = 0.010). Patients with completed PD also displayed a decrease in incisional SSI with use of the wound protector compared with those palliated surgically (27.3% vs 48.7%; P = 0.04). Multivariate analysis did not identify any significant modifying factor relationships (estimated blood loss, duration of surgery, hospital site, etc.) (P > 0.05). CONCLUSION: Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.

Distinguishing Benign from Malignant Pancreatic and Periampullary Lesions Using Combined Use of ¹H-NMR Spectroscopy and Gas Chromatography-Mass Spectrometry.

Previous work demonstrated that serum metabolomics can distinguish pancreatic cancer from benign disease. However, in the clinic, non-pancreatic periampullary cancers are difficult to distinguish from pancreatic cancer. Therefore, to test the clinical utility of this technology, we determined whether any pancreatic and periampullary adenocarcinoma could be distinguished from benign masses and biliary strictures. Sera from 157 patients with malignant and benign pancreatic and periampullary lesions were analyzed using proton nuclear magnetic resonance (¹H-NMR) spectroscopy and gas chromatography-mass spectrometry (GC-MS). Multivariate projection modeling using SIMCA-P+ software in training datasets (n = 80) was used to generate the best models to differentiate disease states. Models were validated in test datasets (n = 77). The final ¹H-NMR spectroscopy and GC-MS metabolomic profiles consisted of 14 and 18 compounds, with AUROC values of 0.74 (SE 0.06) and 0.62 (SE 0.08), respectively. The combination of ¹H-NMR spectroscopy and GC-MS metabolites did not substantially improve this performance (AUROC 0.66, SE 0.08). In patients with adenocarcinoma, glutamate levels were consistently higher, while glutamine and alanine levels were consistently lower. Pancreatic and periampullary adenocarcinomas can be distinguished from benign lesions. To further enhance the discriminatory power of metabolomics in this setting, it will be important to identify the metabolomic changes that characterize each of the subclasses of this heterogeneous group of cancers.

Effect of N-acetylcysteine on liver recovery after resection: A randomized clinical trial.

BACKGROUND AND OBJECTIVES: Liver failure following hepatic resection is a multifactorial complication. In experimental studies, infusion of N-acetylcysteine (NAC) can minimize hepatic parenchymal injury. METHODS: Patients undergoing liver resection were randomized to postoperative care with or without NAC. No blinding was performed. Overall complication rate was the primary outcome; liver failure, length of stay, and mortality were secondary outcomes. Due to safety concerns, a premature multivariate analysis was performed and included within the model randomization to NAC, preoperative ASA, extent of resection, and intraoperative vascular occlusion as factors. RESULTS: Two hundred and six patients were randomized (110 to conventional therapy; 96 to NAC). No significant differences were noted in overall complications (32.7% and 45.7%, P = 0.06) or hepatic failure (3.6% and 5.4%, P = 0.537) between treatment groups. There was significantly more delirium within the NAC group (2.7% and 9.8%, P < 0.05) that caused early trial termination. In multivariate analysis, only randomization to NAC (OR = 2.21, 95%CI = 1.16-4.19) and extensive resections (OR = 2.28, 95%CI = 1.22-4.29) were predictive of postoperative complications. CONCLUSIONS: Patients randomized to postoperative NAC received no benefit. There was a trend toward a higher rate of overall complications and a significantly higher rate of delirium in the NAC group. J. Surg. Oncol. 2016;114:446-450. © 2016 Wiley Periodicals, Inc.

Preoperative single-dose methylprednisolone versus placebo after major liver resection in adults: protocol for a randomised controlled trial.

INTRODUCTION: Although randomised controlled trials have demonstrated that preoperative glucocorticoids may improve postoperative surrogate outcomes among patients undergoing major liver resection, evidence supporting improved patient-important outcomes is lacking. This superiority trial aims to evaluate the effect of administration of a bolus of the glucocorticoid methylprednisolone versus placebo during induction of anaesthesia on postoperative morbidity among adults undergoing elective major liver resection. METHODS AND ANALYSIS: This will be a randomised, dual-arm, parallel-group, superiority trial. All consecutive adults presenting to a large Canadian tertiary care hospital who consent to undergo major liver resection will be included. Patients aged <18 years and those currently receiving systemic corticosteroid therapy will be excluded. We will randomly allocate participants to a preoperative 500 mg intravenous bolus of methylprednisolone versus placebo. Surgical team members and outcome assessors will be blinded to treatment allocation status. The primary outcome measure will be postoperative complications. Secondary outcome measures will include mortality, the incidence of several specific postoperative complications, and blood levels of select proinflammatory cytokines, acute-phase proteins, and laboratory liver enzymes or function tests on postoperative days 0, 1, 2 and 5. The incidence of postoperative complications and mortality will be compared using Fisher's exact test, while the above laboratory measures will be compared using mixed-effects models with a subject-specific random intercept. ETHICS AND DISSEMINATION: This trial will evaluate the protective effect of a single preoperative dose of methylprednisolone on the hazard of postoperative complications. A report releasing study results will be submitted for publication in an appropriate journal, approximately 3 months after finishing the data collection. TRIAL REGISTRATION NUMBER: NCT01997658; Pre-results.

The diagnostic pathway for solid pancreatic neoplasms: are we applying too many tests?

BACKGROUND: The single best diagnostic and staging test for pancreatic cancer remains a contrast-enhanced computed tomography scan. It is frequently the only imaging test required before surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care. MATERIALS AND METHODS: A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume Hepato-Pancreato-Biliary (HPB) service over 4 y (2008-2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was used (P < 0.05). RESULTS: Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasonography and computed tomography for 75 (58%) and 52 (40%), respectively. Patients underwent a mean of 1.3 diagnostic tests after the index study and before consultation with HPB surgery (range: 0-5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests. The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 d, respectively. If four interval tests were conducted, the mean was 69.4 and 122.6 d, respectively. Sixty-two patients (48%) were initially referred to a nonsurgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 d, respectively. This compares to 19.8 and 48.1 d, respectively, in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed before HPB consultation if a nonsurgical referral occurred was 2.1 (versus 0.7 if direct HPB surgeon referral). CONCLUSIONS: Despite a relatively simple algorithm for the investigation of solid pancreatic lesions, considerable heterogeneity remains in how these patients are evaluated before referral to HPB surgery. As the number of investigations increases after the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Education is required to expedite care and mitigate excess diagnostic tests.

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

BACKGROUND: It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD). METHODS: A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and χ(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression. RESULTS: Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003). CONCLUSION: There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

CONTEXTE: Selon certains, la pancréatogastrostomie (PG) est une technique de reconstruction plus sécuritaire que la pancréatojéjunostomie (PJ) et entraîne une morbidité moindre, y compris un taux moins élevé de fuites pancréatiques et une mortalité postopératoire diminuée. Nous avons comparé la PJ et la PG post-pancréatoduodénectomie. MÉTHODES: Un essai clinique randomisé a été conçu et cessé à l'atteinte d'un taux de participation de 50 %. Les patients ont subi une reconstruction par PG ou par PJ. Le paramètre principal était le taux de fistules pancréatiques et les paramètres secondaires étaient la morbidité et la mortalité globales. Nous avons utilisé les tests t de Student, U de Mann­Whitney et du χ2 carré pour l'analyse en intention de traiter. Nous avons calculé l'effet de la randomisation, du score de l'American Society of Anesthesiologists, de la consistance molle du pancréas et du recours à l'endoprothèse pancréatique sur les complications globales et les taux de fistules à l'aide d'une analyse de régression logistique. RÉSULTANTS: Notre essai a regroupé 98 patients. Le taux de fistules pancréatiques a été de 18 % dans le groupe soumis à la PJ et de 25 % dans le groupe soumis à la PG (p = 0,40). Des complications postopératoires sont survenues chez 48 % des patients du groupe soumis à la PJ et chez 58 % du groupe soumis à la PG (p = 0,31). Aucun prédicteur significatif des complications globales n'est ressorti à l'analyse multivariée. Seule la consistance molle du pancréas a permis de prédire la survenue d'une fistule pancréatique (rapport des cotes 5,89, p = 0,003). CONCLUSION: Nous n'avons noté aucune différence quant aux taux de fuites ou de fistules pancréatiques, de complications globales ou de mortalité entre les patients soumis à la PG et à la PJ post-pancréatoduodénectomie.

Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial.

INTRODUCTION: Among surgical oncology patients, incisional surgical site infection is associated with substantially increased morbidity, mortality and healthcare costs. Moreover, while adults undergoing pancreaticoduodenectomy with preoperative placement of an intrabiliary stent have a high risk of this type of infection, and wound protectors may significantly reduce its risk, no relevant studies of wound protectors yet exist involving this patient population. This study will evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among adults undergoing pancreaticoduodenectomy with preoperatively-placed intrabiliary stents. METHODS AND ANALYSIS: This study will be a parallel, dual-arm, randomised controlled trial that will utilise a more explanatory than pragmatic attitude. All adults (≥18 years) undergoing a pancreaticoduodenectomy at the Foothills Medical Centre in Calgary, Alberta, Canada with preoperative placement of an intrabiliary stent will be considered eligible. Exclusion criteria will include patient age <18 years and those receiving long-term glucocorticoids. The trial will employ block randomisation to allocate patients to a commercial dual-ring wound protector (the Alexis Wound Protector) or no wound protector and the current standard of care. The main outcome measure will be the rate of surgical site infection as defined by the Centers for Disease Control and Prevention criteria within 30 days of the index operation date as determined by a research assistant blinded to treatment allocation. Outcomes will be analysed by a statistician blinded to allocation status by calculating risk ratios and 95% CIs and compared using Fisher's exact test. ETHICS AND DISSEMINATION: This will be the first randomised trial to evaluate the efficacy of a dual-ring wound protector for prevention of incisional surgical site infection among patients undergoing pancreaticoduodenectomy. Results of this study are expected to be available in 2016/2017 and will be disseminated using an integrated and end-of-grant knowledge translation strategy. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier NCT01836237.

Identification of prognostic inflammatory factors in colorectal liver metastases.

BACKGROUND: The modified Glasgow Prognostic Score (mGPS) has been reported to be an important prognostic indicator in a number of tumor types, including colorectal cancer (CRC). The features of the inflammatory state thought to accompany elevated C-reactive protein (CRP), a key feature of mGPS, were characterized in patients with colorectal liver metastases. Additional inflammatory mediators that contribute to prognosis were explored. METHODS: In sera from 69 patients with colorectal liver metastases, a panel of 42 inflammatory mediators were quantified as a function of CRP levels, and as a function of disease-free survival. Multivariate statistical methods were used to determine association of each mediator with elevated CRP and truncated disease-free survival. RESULTS: Elevated CRP was confirmed to be a strong predictor of survival (HR 4.00, p = 0.001) and recurrence (HR 3.30, p = 0.002). The inflammatory state associated with elevated CRP was comprised of raised IL-1ß, IL-6, IL-12 and IL-15. In addition, elevated IL-8 and PDGF-AB/BB and decreased eotaxin and IP-10 were associated with worse disease-free and overall survival. CONCLUSIONS: Elevated CRP is associated with a proinflammatory state. The inflammatory state is an important prognostic indicator in CRC liver metastases. The individual contributions of tumor biology and the host to this inflammatory response will require further investigation.

The impact of an acute care surgery clinical care pathway for suspected appendicitis on the use of CT in the emergency department.

BACKGROUND: The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED). METHODS: All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: pre- and postimplementation of the disease-specific pathway and at 12-month follow-up. RESULTS: Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month followup (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040). CONCLUSION: A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention.

CONTEXTE: LL'évolution naturelle d'un service de chirurgie d'urgence (SCU) consiste à mettre au point des plans d'intervention spécifiques aux maladies dans le but d'améliorer la qualité des soins. Notre objectif principal était d'évaluer l'impact de l'instauration au SCU d'un plan d'intervention spécifique à l'appendicite présumée sur le roulement des patients et sur l'utilisation de la tomodensitométrie (TDM) à l'urgence. MÉTHODES: Les dossiers de tous les patients adultes d'un important réseau de santé (3 hôpitaux) s'étant présentés pour une appendicite présumée ont été analysés durant la période de notre étude qui incluait 3 étapes : avant et après la mise en oeuvre du plan d'intervention spécifique, puis suivi à 12 mois. RÉSULTATS: Sur les 1168 consultations pour appendicite qui ont eu lieu durant notre étude, 349 se sont déroulées avant la mise en oeuvre du service, 392, après sa mise en oeuvre, et 427 étaient des visites de suivi. En tout, 877 patients (75 %) ont été admis au SCU. Globalement, 83 % des patients ont subi une chirurgie dans les 6 heures. Le temps d'attente moyen entre la demande de TDM et sa réalisation a diminué après l'application du plan d'intervention pour tous les sites (197 c. 143 min, p < 0,001). Cette amélioration se maintenait toujours au suivi de 12 mois (131 min, p < 0,001). Le plan d'intervention a permis de faire passer le nombre de TDM réalisées en moins de 2 heures de 3 % à 42 % (p < 0,001). On n'a noté aucune diminution du nombre total de TDM ou des tendances de l'échographie (p = 0,42). Les temps d'attente entre le triage et l'appendicectomie ont diminué (665 min avant et 633 min après l'application du plan d'intervention, 631 min au suivi de 12 mois, p = 0.040). CONCLUSION: Un plan d'intervention spécifique à l'appendicite peut réduire les temps d'attente pour la TDM et l'intervention chirurgicale.