Prognosis in acute pancreatitis associated with HIV infection.

BACKGROUND: This prospective study compared scoring systems in predicting adverse outcomes in HIV associated acute pancreatitis (HIV+ve AP) METHODS: Systemic inflammatory response syndrome (SIRS), Glasgow criteria, C-reactive protein (CRP), bedside index of severity in acute pancreatitis (BISAP) and APACHE II scores using standard cut-off values were used to predict the endpoint of moderate and severe disease in HIV-ve and HIV+ve patients and in CD4 counts above and below 200 cells/mm3. RESULTS: Ninety (38%) of 238 patients with AP were HIV+ve. Fifteen had organ failure, 33 local complications and 12 patients died. Advanced age was not associated with severe disease. The APACHE II was the best predictor of severe disease in HIV+ve (AUC 0.88) and HIV-ve patients (AUC 0.81) and CRP was the poorest predictor (AUC 0.59) in HIV+ve patients. In HIV+ve patients with CD4 counts greater and less than 200 cells/mm3 the Glasgow and APACHE II scores were the best prognosticators (AUC > 0.8) and BISAP in patients with CD4 > 200 cells/mm3 (AUC 0.90). CONCLUSION: The APACHE II score was most effective irrespective of HIV status whereas the BISAP scores was better in CD4 > 200 cells/mm3.

Personal Protective Equipment for Endoscopy in Low-Resource Settings During the COVID-19 Pandemic: Guidance From the World Gastroenterology Organisation.

Performance of endoscopic procedures is associated with a risk of infection from COVID-19. This risk can be reduced by the use of personal protective equipment (PPE). However, shortage of PPE has emerged as an important issue in managing the pandemic in both traditionally high and low-resource areas. A group of clinicians and researchers from thirteen countries representing low, middle, and high-income areas has developed recommendations for optimal utilization of PPE before, during, and after gastrointestinal endoscopy with particular reference to low-resource situations. We determined that there is limited flexibility with regard to the utilization of PPE between ideal and low-resource settings. Some compromises are possible, especially with regard to PPE use, during endoscopic procedures. We have, therefore, also stressed the need to prevent transmission of COVID-19 by measures other than PPE and to conserve PPE by reduction of patient volume, limiting procedures to urgent or emergent, and reducing the number of staff and trainees involved in procedures. This guidance aims to optimize utilization of PPE and protection of health care providers.

Pancreatitis in a high HIV prevalence environment.

BACKGROUND: Acute pancreatitis is common in HIV-positive individuals in reports from regions with a low incidence of HIV infection. This association has not been reported in areas with a high incidence of HIV infection. OBJECTIVE: To examine the prevalence and outcomes of HIV-associated acute pancreatitis in a high HIV prevalence environment, and trends over the period May 2001 - November 2010. METHODS: The records of patients admitted with acute pancreatitis from 2001 to 2010 were reviewed, looking for HIV status, CD4 counts and medications at presentation. The Glasgow criteria, organ failure, local complications and mortality were assessed. RESULTS: One hundred and six (16.9%) of 627 patients admitted with acute pancreatitis during the study period were infected with HIV. Most were female (65.1%) and black African (91.5%). The serum amylase level was used to confirm acute pancreatitis in 50 patients, with a mean of 1 569 IU/L (range 375 - 5 769), and urinary amylase in 56 patients, with a mean of 4 083 IU/L (range 934 - 36 856). Alcohol was a less frequent cause of pancreatitis in the HIV-positive group than in patients who were HIV-negative (24.5% v. 68.3%), and the prevalence of gallstones as a cause was similar (23.6% v. 17.9%). Antiretroviral therapy was associated with pancreatitis in 35.8%, and 6 (5.7%) had abdominal malignancies. Sixteen (15.1%) had pancreatic necrosis, 20 (18.9%) had septic complications, and 6 (5.7%) died. CONCLUSIONS: HIV-associated acute pancreatitis was most frequent in females and black Africans and was associated with malignancy. Mortality was similar in HIV and non-HIV pancreatitis.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification.

AIM: To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries. METHODS: A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied. RESULTS: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. CONCLUSION: This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective.

BACKGROUND: Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience. PATIENTS AND METHODS: All patients who had SEMS placement for oesophageal cancer at Grey's Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007-2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications. RESULTS: A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age>70 years n=95 patients, tumour>8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality. CONCLUSION: The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance.

The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of 48 patients treated at a tertiary institution.

BACKGROUND: Endoscopic retrograde pancreatography (ERP) is useful in the diagnosis and treatment of selected patients with pancreatic trauma. We analyzed the role of ERP in treating persistent complications of pancreatic injuries at a tertiary institution. METHODS: Patients with pancreatic trauma who underwent ERP were identified from a prospective database of 426 pancreatic injuries from January 1983 to January 2011. Patient demographics, mechanism of injury, time to presentation, method of diagnosis, associated injuries, clinical management, endoscopic interventions and their timing, surgical treatment, and patient outcomes were evaluated. RESULTS: Forty-eight patients underwent ERP after blunt (n = 26) or penetrating (n = 22) pancreatic injury. Median time from injury to ERP was 38 days (range, 2-365 days). Diagnostic ERP was successful in 47 patients. In 11 patients, ERP demonstrated an intact main duct with minor peripheral injuries, and no further intervention was required. A pancreatic fistula was demonstrated in 24, a main pancreatic duct stricture in 12, and a pseudocyst in 10 patients. Fifteen patients had a pancreatic duct sphincterotomy, seven had a pancreatic stent inserted, and six had an endoscopic pseudocyst drainage. Ten patients ultimately required surgery, seven of whom had demonstrated a severe pancreatic duct stricture. Operations performed following ERP were distal pancreatectomy (n = 6), pancreaticojejunostomy (n = 3) and cyst-jejunostomy (n = 1). CONCLUSION: ERP allowed one quarter of the patients to be treated conservatively. Half had a successful intervention by ERP. Success was most likely in those with fistulae and pseudocysts. Surgery was ultimately avoided in more than three quarters of the patients. LEVEL OF EVIDENCE: Therapeutic study, level V.

The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education.

INTRODUCTION: This audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs. METHODS: At a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors. RESULTS: During the period July 2009-2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3). CONCLUSIONS: Rural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma.

Use of amylase and alanine transaminase to predict acute gallstone pancreatitis in a population with high HIV prevalence.

BACKGROUND: The etiology of acute pancreatitis can be difficult to determine early in the course of the disease. The aim of the present study was to determine the relationship between biochemical parameters and the cause of acute pancreatitis. METHODS: A prospectively collected database of patients admitted with acute pancreatitis between 2001 and 2008 was analyzed. The relationships between etiology and age, sex, admission serum amylase level, and admission alanine transaminase (ALT) level were evaluated. RESULTS: Acute pancreatitis was diagnosed in 464 patients. The disease was related to alcohol in 275 cases, gallstones in 81 cases, HIV in 49 cases, dyslipidemia in 42 cases, and it was idiopathic in 17 cases. Alcoholic pancreatitis was more common in men, whereas the other identifiable causes were more common in women (P < 0.001). Mean age at presentation was 39 years with no difference in age in relation to etiology (P = 0.057). When compared to patients with non-biliary causes of pancreatitis, patients with gallstone pancreatitis had greater median (range) serum amylase activity [1,423 U/l (153-7,500 U/l) versus 589 U/l (58-11,144 U/l); P < 0.001] and ALT activity [153 U/l (8-13,233 U/l) versus 31 U/l (6-421 U/l); P < 0.001]. No significant differences in amylase or ALT activity were found between non-biliary etiologies (P > 0.05). Alanine transaminase was the only factor independent of sex to predict gallstone etiology, with activity >150 U/l having a specificity of 97 %. CONCLUSIONS: In patients with acute gallstone pancreatitis, the serum amylase and ALT activities were more than double those of other etiologies. An ALT level of >150 U/l was highly predictive of gallstone etiology independent of gender. Neither amylase nor ALT could differentiate non-biliary etiologies. The combination of amylase and ALT offered no improvement in predicting etiology over each alone.

The efficacy of endoscopic therapy in bleeding peptic ulcer patients.

BACKGROUND: Endotherapy is the primary modality for the control of bleeding from peptic ulceration. OBJECTIVE: To assess the efficacy of endoscopic intervention for high-risk bleeding peptic ulcer disease and to benchmark our surgical and mortality rates. METHODS: Two hundred and twenty-seven patients with peptic ulcers stratified by Rockall and Forrest scores as at high risk for re-bleeding underwent therapeutic intervention (adrenalin injection) between January 2004 and December 2009. The median age of the patients was 57 years (range 19 - 87 years); 60% were males. Results. Primary endoscopic haemostasis failed in 51/227 patients (22.5%); 18 patients (7.9%) required surgery for bleeding not controlled at initial or second endoscopy; and 29 patients (12.8%) died, 12 by day 3 and 17 by day 30. Fifteen patients, all with significant medical co-morbidity, died after successful primary endotherapy, and 4 died after surgery. Surgical patients required more blood (odds ratio (OR) 1.45, p=0.0001) than those not undergoing surgery, but had similar mortality. Rebleeding was the only predictor of death in patients who died by day 3 (OR 18.77). A high Rockall score was the only predictor of death by day 30 (OR 1.98). CONCLUSION: The overall surgical and mortality rates were 7.9% and 12.8%, respectively. Over half the deaths resulted from medical co-morbidity, despite successful primary endotherapy. This finding is supported by the use of the Rockall score as a predictor of mortality at day 30. Improving the technical success of primary endoscopic haemostasis, currently 77.5%, has the potential to reduce rebleeding after primary endotherapy, a predictor of death at day 3 in this study.

Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities.

INTRODUCTION: In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy. METHODS: All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death. RESULTS: Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18­40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80­90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group. CONCLUSION: Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.

Pancreatico-enterostomy for isolated main pancreatic duct disruption.

BACKGROUND: We present our experiences with isolated main pancreatic duct injuries due to blunt trauma, managed by pancreatico-enterostomies. METHODS: This is a retrospective study of seven patients, one female and six males who presented between 1997 and 2005, whose ages ranged from 10 to 54 years. Three were due to motor vehicle accidents, two due to blunt assault, one pedestrian vehicle accident and one go-cart accident. Four presented acutely and were managed surgically within 24h; two were delayed by 3 days and one by 14 days. Six had pre-operative CT scans; one had an ERCP confirming ductal transection by contrast extravasation. RESULTS: Five pancreatico-gastrostomies and two pancreatico-jejenostomies were performed. Three patients complicated; one by biliary cutaneous fistula after a left hepatic segmentectomy, one with an amylase-rich low output fistula and one with haematemesis, for which no cause could be identified. All complications were managed conservatively. Post-operative follow-up ranged between 4 and 20 weeks. No deaths occurred. CONCLUSION: In a stable patient, pancreatico-enterostomy for an isolated main pancreatic duct injury appears to be a viable option and simpler to perform than distal pancreatectomy with splenic preservation. Furthermore, it has the advantage of pancreatic tissue and spleen preservation and a low fistula rate. The authors believe pancreatico-gastrostomy to be the easier to perform.

Palliation of malignant hilar obstruction at a single centre--review of operative and non-operative techniques.

INTRODUCTION: Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction. PATIENTS AND METHODS: All patients with malignant hilar obstruction managed at our institution during the period 1992-2002 were identified for review. RESULTS: A total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors. CONCLUSION: Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.

Isolated main pancreatic duct injuries spectrum and management.

BACKGROUND: We present our experience with the rare injury of isolated major pancreatic duct disruption. METHODS: From 1997 to 2003, 3 females and 13 males whose age ranged from 4 to 46 years were identified. Stabs caused 2 and blunt trauma 14 injuries. Nine presented acutely. Delay occurred in 7 patients, 6 with pseudocysts and 1 with infected pancreatic necrosis. RESULTS: Nine cases were managed in the acute phase: 6 by splenic-preserving distal pancreatectomy and 2 by distal pancreatico-enteric anastomosis; 1 was drained. A small pseudocyst and transient pancreatic fistula were the only complications. The 6 cases with pseudocysts were managed endoscopically. Five were stented and 1 was drained without stent. Four had resolution. Two had stent cyst migration. One required a pancreaticojejunostomy and another distal pancreatectomy. One patient died of infected pancreatic necrosis. Long-term outcome could not be assessed. CONCLUSION: In the acute situation, resection or distal pancreatico-enteric anastomoses are attainable with low morbidity. Endoscopic pseudocyst management options are feasible, with good short-term resolution. Giant cysts may be better managed operatively.