Postoperative pancreatic fistula: a review of traditional and emerging concepts.

Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.

Endoscopic large balloon sphincteroplasty is a useful, safe adjunct for difficult to treat choledocholithiasis.

BACKGROUND: The aim of this study was to assess the safety and efficacy of large balloon sphincteroplasty when used in conjunction with endoscopic biliary sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) for therapy of choledocholithiasis. METHODS: A retrospective audit of all ERCP's performed for choledocholithiasis between January 2012 and October 2013 at one institution was performed. Procedures that utilized large balloon sphincteroplasty were compared with those underwent standard endoscopic stone extraction. Outcomes including stone clearance rate for the individual procedure type, post-ERCP complications and need for surgical exploration of the bile duct were documented. RESULTS: A total of 346 procedures on 306 patients that met the inclusion criteria were identified. Fifty-four (15.6%) procedures included large balloon sphincteroplasty and were compared with 292 (84.4%) procedures that used standard balloon extraction techniques. Despite those patients in the large balloon sphincteroplasty group having a higher rate of previous ERCP (33.3% versus 19.5%, P = 0.031) and a larger proportion of patients with stones greater than 10 mm (40.3% versus 11.3%, P < 0.001), the overall initial clearance rate was similar at 83%. Ultimately, only 14 out of 306 (4.6%) of all patients required surgical intervention. There was no significant difference in the rate of post-ERCP pancreatitis between the two groups (5.6% versus 3.8%, P = 0.466). CONCLUSION: Large balloon sphincteroplasty of the sphincter of Oddi is a safe and effective adjunct to endoscopic biliary sphincterotomy in difficult to treat choledocholithiasis. The current study demonstrated large balloon sphincteroplasty did not result in more complications despite a tendency to being used for larger stones.

Hemostasis and thrombosis in major liver resection.

The liver plays an important role in the balance between hemostasis and thrombosis. Hepatic resection, particularly when performed in the presence of underlying parenchymal liver disease, can cause perturbation of this balance. This review summarizes the changes that occur in normal hemostasis and thrombosis before, during, and after nontransplant hepatic resection and, wherever possible, provides strategies for the perioperative management of bleeding and thrombosis.

Using a standardized method for laparoscopic cholecystectomy to create a concept operation-specific checklist.

OBJECTIVES: Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI. METHODS: A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist. RESULTS: A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography. CONCLUSIONS: A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.

Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis.

BACKGROUND: Cap-assisted colonoscopy uses a transparent plastic hood attached to the tip of the colonoscope to flatten the semilunar folds and improve mucosal exposure. Several studies have examined the effect of cap-assisted colonoscopy on polyp detection, but the data are inconsistent. OBJECTIVE: This study aimed to evaluate whether cap-assisted colonoscopy improves the yield of colorectal neoplasia detected compared with standard colonoscopy. DATA SOURCES: A systematic search of the PubMed, MEDLINE, Embase, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction. STUDY SELECTION: Publications that compared cap-assisted colonoscopy vs standard colonoscopy in adults in a prospective randomized controlled study were selected for review. MAIN OUTCOME MEASURES: The primary outcomes used for meta-analysis were cecal intubation rate, cecal intubation time, and polyp detection rate. The analysis was performed using a fixed-effect model. Outcomes were calculated as odds ratios or standardized mean differences with 95% confidence intervals. The average polyp miss rate determined by tandem colonoscopy was also calculated. RESULTS: The outcomes of 6185 patients were studied. Cap-assisted colonoscopy detected significantly more patients with polyps (OR 1.13; p = 0.030) and had a lower average polyp miss rate (12.2% vs 28.6%) than standard colonoscopy. Cap-assisted colonoscopy had a significantly higher cecal intubation rate than standard colonoscopy (OR 1.36; p = 0.020), whereas the time to cecal intubation (standard mean difference, 0.04 min; p = 0.280) was similar for the 2 colonoscope types. CONCLUSIONS: Cap-assisted colonoscopy is associated with improved detection of colorectal neoplasia and higher cecal intubation rates than standard adult colonoscopy.

Alanine transaminase rather than abdominal ultrasound alone is an important investigation to justify cholecystectomy in patients presenting with acute pancreatitis.

OBJECTIVES: The aims of this study were to investigate the predictive value of an elevated level of alanine transaminase (ALT) for biliary acute pancreatitis (AP) and to reconsider the role of abdominal ultrasound (AUS). METHODS: All patients admitted to Christchurch Public Hospital with AP between July 2005 and December 2008 were identified from a prospectively collected database. Peak ALT within 48 h of presentation was recorded. Aetiology was determined on the basis of history, AUS and other relevant investigations. RESULTS: A total of 543 patients met the inclusion criteria. Patients with biliary AP had significantly higher median (range) ALT than those with non-biliary causes (200 units/l [63-421 units/l] vs. 33 units/l [18-84 units/l]; P < 0.001). An ALT level of >300 units/l had a sensitivity of 36%, specificity of 94%, positive predictive value of 87% and positive likelihood ratio of 5.6 for gallstones. An elevated ALT and negative AUS had a probability of 21-80% for gallstones. CONCLUSIONS: An elevated ALT strongly supports a diagnosis of gallstones in AP. Abdominal ultrasound effectively confirms this diagnosis; however, a negative ultrasound in the presence of a raised ALT does not exclude gallstones. In some patients consideration could be given to proceeding to laparoscopic cholecystectomy based on ALT alone.

Cumulative sum (Cusum) analysis provides an objective measure of competency during training in endoscopic retrograde cholangio-pancreatography (ERCP).

BACKGROUND AND AIM: Endoscopic retrograde cholangio-pancreatography (ERCP) is a complex and technically challenging procedure with a risk of significant complications. Although recommendations exist as to how many ERCPs should be performed before a trainee is deemed competent they lack objective measures of outcome. Cumulative sum (Cusum) analysis allows continuous monitoring of a proceduralist's performance to ensure acceptable outcomes are being achieved. The aim of the present study was to assess a trainee's progress with ERCP using Cusum analysis. METHOD: A single trainee performed one supervised ERCP list per week between June 2005 and May 2008. Prospective data were collected and analysed by intention to treat using Cumulative failure charting and Cusum analysis. The binary outcome measure was successful cannulation in patients with a native sphincter. Acceptable and unacceptable cannulation failure rates were set at 20% and 35% respectively, with Type I and II error rates set at 0.10. RESULTS: A total of 290 ERCPs were performed. Successful cannulation was achieved in 168 of 238 (70.6%) patients with intact biliary sphincters. Although cumulative failure charting suggested the trainee had not yet achieved satisfactory performance, Cusum analysis with sequential probability ratio testing indicated that an acceptable outcome had been achieved for the last 179 consecutive ERCPs. CONCLUSION: Cusum analysis enables sensitive and continuous monitoring of a trainee's performance to objectively determine competency. Wider and systematic use may enable appropriate benchmarks to be identified and more objective assessment of a trainee's experience.

Closing the audit loop is necessary to achieve compliance with evidence-based guidelines in the management of acute pancreatitis.

AIM: The aim of this study was to assess the effect of the implementation of evidence-based guidelines and subsequent feedback to surgeons in the management of acute pancreatitis. METHOD: An evidence-based Pancreatitis Proforma was developed. Data were prospectively recorded (01/06/2005-30/09/2007). Audit feedback (AFB) was performed at 9 months. A final analysis was performed comparing outcomes pre- and post-audit feedback. RESULTS: 372 patients were included. Median age (range) was 57 (12-96) years. 168 (45.2%) patients were admitted pre-AFB. Post-AFB, there was a significant increase in the number of patients whose diagnosis was made within 48 hours (135/168 (80.4%) vs 189/204 (92.6%), p<0.001) and who underwent definitive treatment for mild biliary pancreatitis (33/61 (54.1%) vs 56/70 (80.0%), p=0.002). Post-AFB there was also a significant reduction in the number of computed tomography (CT) scans performed for patients with mild acute pancreatitis (23/85 (27.1%) vs 13/99 (13.1%), p=0.018). Mortality (9/168 (5.4%) vs 3/204 (1.4%), p=0.040) also decreased. On multivariate analysis, AFB was an independent factor for change in the use of CT scans (p=0.015) and management of patients with mild biliary pancreatitis (p=0.039). CONCLUSION: For evidence-based guidelines to be effective, feedback to surgeons is necessary.

Incidental pancreatic cystic lesions.

INTRODUCTION: Incidental pancreatic cystic lesions (IPCL) are becoming an increasingly frequent clinical entity. Within this review, the differential diagnosis, investigation, and management are discussed. METHODS: A MEDLINE search was performed for IPCL. RESULTS: Incidence of IPCL varies from 0.2-0.7%, and 30-47% are premalignant or malignant. Pancreatic pseudocysts (PC), serous cystic neoplasms (SCN), intraductal papillary mucinous neoplasms (IPMN), and mucinous cystic neoplasms (MCN) are the most common pathological entities of IPCL. The use of combined modalities, including clinical characteristics, serum tumor markers, cross-sectional imaging, and endoscopic ultrasound (EUS) with cyst fluid analysis should all be used to establish an accurate preoperative diagnosis if possible. Modern multidetector computed tomography (MDCT) and magnetic resonance pancreatography (MRP) allow detailed characterization of IPCL, including size, septation, calcifications, mural nodules, and communication with main pancreatic duct. The best available cyst fluid markers of mucinous neoplasm are viscosity > or =1.6 and carcinoembryonic antigen >192 ng/ml. Although surgery is indicated for MCN or main or mixed duct IPMN, recent advances in the understanding of the natural history and increasingly accurate preoperative diagnosis allow a nonoperative approach to be undertaken for the majority of IPCL. For those treated nonoperatively, the ideal follow-up has yet to be determined. CONCLUSIONS: Emerging evidence supports selective nonoperative management for the majority of patients who have IPCL when investigated by a multimodal approach. For those in whom a suspicion of malignancy remains, surgery is indicated.