The Modified Early Warning Score (MEWS): an instant physiological prognostic indicator of poor outcome in acute pancreatitis.

CONTEXT: The Modified Early Warning Score (MEWS) is a bedside scoring system that is non-invasive, simple and repeatable to reflect dynamic changes in physiological state. OBJECTIVE: This study aims to assess accuracy of MEWS and determine an optimal MEWS value in predicting severity in acute pancreatitis (AP). METHODS: A prospective database of consecutive admissions with AP to a single institution was analysed to determine value of MEWS in identifying severe acute pancreatitis (SAP) and predicting poor outcome. Receiver operator curves (ROC) were used to determine optimal accuracy. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were calculated for the optimal MEWS values obtained. RESULTS: One-hundred and 42 patients with AP were included. The optimal highest MEWS per 24 hours period (hMEWS) and mean MEWS per 24 hour period (mMEWS) in predicting SAP as determined by ROC were 2.5 and 1.625 respectively; with hMEWS ≥3 and mMEWS >1 utilised in this cohort as MEWS scores are whole numbers. On admission, sensitivity, specificity, NPV, PPV, and accuracy of hMEWS ≥3 was 95.5%, 90.8%, 99.0%, 65.6% and 92.0%; and for mMWES >1 was 95.5%, 87.5%, 99.0%, 58.3% and 88.7%, both superior than the Imrie score: 31.5%, 92.1%, 88.9%, 40.0% and 83.5%. The accuracy of hMEWS ≥3 and mMEWS >1 increased over the subsequent 72 hours (days 0-2) from 92 to 96%, and 89% to 94%, respectively. CONCLUSIONS: MEWS provides a novel, easy, instant, repeatable, reliable prognostic score that may be superior to existing scoring systems. A larger cohort is required to validate these findings.

Laparoscopic bile duct exploration via choledochotomy followed by primary duct closure is feasible and safe for the treatment of choledocholithiasis.

BACKGROUND: The common bile duct traditionally is managed with T-tube drainage after choledochotomy and removal of common bile duct (CBD) stones, but this approach carries an associated tube-related morbidity rate, including bile leak, of 10.5-20 %. This study examined the safety and effectiveness of laparoscopic CBD exploration (LCBDE) followed by primary duct closure. METHODS: This is a retrospective analysis of 120 consecutive patients (81 female) who underwent LCBDE between October 2002 and October 2012. The duct primarily was closed in all patients. The results are given as median (range). RESULTS: Trans-CBD exploration was performed in 120 patients and all cases were successfully completed laparoscopically. The maximum diameter of the CBD was 9.4 (3-30) mm and the number of CBD stones detected was 3 (0-20). The biliary tree was clear at the end of exploration in 116 patients (96.7 %). The operating time was 122 (70-360) min. The mortality rate, morbidity rate, postoperative bile leak rate, rate of retained CBD stones after the primary procedure, and CBD stricture rate at a follow-up of 39.2 (2-82) months were 0, 8.3, 2.5, 3.3, and 0.8 %, respectively. The postoperative hospital stay was 2.1 (1-29) days. CONCLUSION: Primary duct closure following LCBDE is safe, can be employed routinely as an alternative to T-tube insertion, and has a short hospital stay and low morbidity rate.

Results of pancreatic surgery in the elderly: is age a barrier?

BACKGROUND: By 2033, the number of people aged 85 years and over in the UK is projected to double, accounting for 5% of the total population. It is important to understand the surgical outcome after a pancreatic resection in the elderly to assist decision making. METHODS: Over a 9-year period (from January 2000 to August 2009), 428 consecutive patients who underwent a pancreatic resection were reviewed. Data were collected on mortality, complications, length of stay and survival. Patients were divided into two groups (younger than 70 and older than 70 years old) and outcomes were analysed. RESULTS: In all, 119 (27.8%) patients were ≥ 70 years and 309 (72.2%) patients were < 70 years. The median length of stay for the older and younger group was 15 days (range 3-91) and 14 days (range 3-144), respectively. The overall mortality was 3.4% in the older group and 2.6% in the younger group (P = 0.75). The older cohort had a cumulative median survival of 57.3 months (range 0-119), compared with 78.7 months (range 0-126) in the younger cohort (P < 0.0001). In patients undergoing a pancreatic resection for ductal adenocarcinoma and cholangiocarcinoma there was a significant difference in survival with P-values of 0.043 and 0.003, respectively. For ampullary adenocarcinoma, the older group had a median survival of 47.1 months compared with 68.3 months (P = 0.194). CONCLUSION: Results from this study suggest that while elderly patients can safely undergo a pancreatic resection and that age alone should not preclude a pancreatic resection, there is still significant morbidity and mortality in the octogenarian subgroup with poor long-term survival with the need for quality-of-life assessment.

Pancreatic carcinoma masquerading as groove pancreatitis: case report and review of literature.

CONTEXT: Groove pancreatitis is a distinct form of chronic pancreatitis affecting the space surrounded by the pancreatic head, duodenum and common bile duct. It is an uncommon pancreatic disease with challenging imaging diagnosis that can lead to surgical dilemmas. The purpose of this study is to report a case and review the current clinical, radiological and pathological characteristics of groove pancreatic carcinoma and groove pancreatitis. CASE REPORT: A 58-year-old man, with a history of alcohol excess, presented with a 4 month history of upper abdominal pain associated with weight loss and vomiting. Failed duodenal dilatation led to gastroenterostomy with biopsies showing chronic inflammation. Further presentation with jaundice and pancreatic groove mass led to a Whipple's pancreaticoduodenectomy. Histopathology report demonstrated cystic areas in both medial and lateral walls of his duodenum microscopically consistent with groove pancreatitis and a moderate to poorly differentiated adenocarcinoma. CONCLUSION: Several studies have been attempted to clarify the points of differentiation between carcinoma and pancreatitis in the groove area. This discrimination has been proved to be difficult; frequently the definitive diagnosis is only obtained after surgical intervention. This condition should be considered when making the differential diagnosis in pancreatic groove pathology and duodenal stenosis.

Inferior vena cava resection with hepatectomy: challenging but justified.

OBJECTIVE: The aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours. METHODS: From February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database. RESULTS: Resections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients. CONCLUSIONS: Aggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.

A Case-matched Comparative Study of Laparoscopic Versus Open Distal Pancreatectomy.

INTRODUCTION: Although the laparoscopic approach to distal pancreatectomy for benign and malignant diseases is largely replacing open surgery in some centers, well-designed studies comparing these approaches are limited. We present a case-matched study that compares the outcomes of laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP). METHODS: Of 112 patients (51 female) who underwent surgery between January 2002 and December 2011, 44 patients were matched on a 1:1 basis (22 LDP, 22 ODP) according to age, sex, and tumor size. Outcomes were compared on an intention-to-treat basis. Data shown represent median where appropriate. RESULTS: The laparoscopic and open groups were comparable for age (57 vs. 59.9 y, P=0.980), sex distribution (P=1.000), tumor size (3 vs. 4 cm, P=0.904), and the frequency of benign versus malignant disease (P=0.920). LDP was associated with significantly lower blood loss (100 vs. 500 mL, P=0.001), higher spleen preservation rate (45% vs. 18%, P=0.029), as well as shorter high dependency unit stay (1 vs. 5 d, P=0.001) and postoperative hospital stay (5 vs. 14 d, P=0.017). There was no significant difference in operating time (245 vs. 240 min, P=0.602) and postoperative morbidity (13.6% vs. 27.2%, P=0.431). In patients with malignant disease, there were no differences in R0 resection margin status (90% vs. 85.7%, P=0.88), the numbers of lymph nodes retrieved (12.7 vs. 14.1, P=0.82), the 1- and 2-year survival rates (89% vs. 81%, P=0.54 and 74.2% vs. 71.5%, P=0.63, respectively), and the mean duration of survival (45 vs. 31 mo, P=0.157). CONCLUSIONS: The laparoscopic approach to distal pancreatectomy offers advantages over open surgery in terms of reductions in operative trauma and duration of postoperative recovery without compromising the oncologic resection.

Review of the diagnosis, classification and management of autoimmune pancreatitis.

Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis, with as yet undetermined incidence and prevalence in the general population. Our understanding of it continues to evolve. In the last few years, 2 separate subtypes have been identified: type 1 AIP has been recognised as the pancreatic manifestation of a multiorgan disease, named immunoglobulin G4 (IgG4)-related disease while type 2 AIP is a pancreas specific disorder not associated with IgG4. International criteria for the diagnosis of AIP have been defined: the HISORt criteria from the Mayo clinic, the Japan consensus criteria and, most recently, the international association of pancreatology "International Consensus Diagnostic Criteria". Despite this, in clinical practice it can still be very difficult to confirm the diagnosis and differentiate AIP from a pancreatic cancer. There are no large studies into the long-term prognosis and management of relapses of AIP, and there is even less information at present regarding the Type 2 AIP subtype. Further studies are necessary to clarify the pathogenesis, treatment and long-term outcomes of this disease. Critically for clinicians, making the correct diagnosis and differentiating the disease from pancreatic cancer is of the utmost importance and the greatest challenge.

Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: a case-matched comparative study.

BACKGROUND: Cystgastrostomy is the commonest method of internal drainage of pancreatic pseudocysts (PPs). While large and persistent retrogastric pancreatic pseudocysts are amenable to laparoscopic cystgastrostomy, the potential benefits of this minimally invasive laparoscopic approach over open surgery remain to be demonstrated. The aim of this study was to compare the outcomes of the laparoscopic and open approaches for cystgastrostomy. METHODS: Patients who underwent laparoscopic cystgastrostomy (LCG) were matched on a 3:1 basis to those who underwent open cystgastrostomy (OCG) according to age, sex distribution, and size of pseudocyst. The outcomes of the two approaches were compared on an intention-to-treat basis. Data shown represent medians. RESULTS: A total of 54 patients underwent cystgastrostomy (35 LCG, 19 OCG) between 1997 and 2011. The final case matched cohort consisted of 40 patients (12 female and 28 male) of which 30 underwent LCG (two converted to open surgery) and 10 underwent OCG. The laparoscopic and open groups were comparable for age (55 vs. 59 years, P = 0.80), sex distribution, and size of pseudocyst (10 vs. 13 cm, P = 0.51). The laparoscopic approach had a significantly shorter operating time (62 vs. 95 min, P = 0.035) and carried a significantly lower risk of postoperative morbidity (10% vs. 60%, P = 0.024) and shorter postoperative hospital stay (6.2 vs. 11 days, P = 0.038). There was one operative death after OCG (10%). CONCLUSION: The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a shorter operating time, smoother and more rapid recovery, and a shorter hospital stay compared with open surgery. The laparoscopic approach should be considered the preferable approach where expertise is available.

The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR.

INTRODUCTION: The neutrophil-lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction. MATERIALS AND METHODS: NLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification. RESULTS: One hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3 days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63-90 %, specificities of 50-57 %, negative predictive value of 89.5-96.4 %, positive predictive values of 21.2-31.1 %, and accuracies of 57.7-60 %. CONCLUSIONS: Elevation of the NLR during the first 48 h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.

Transplantation in adults with primary hyperoxaluria: single unit experience and treatment algorithm.

BACKGROUND: Kidney transplantation alone in Primary Hyperoxaluria is associated with a high rate of recurrence and in many cases early graft loss. Liver transplantation offers the possibility of correcting the metabolic defect. MATERIAL/METHODS: A retrospective review of five cases of Primary Hyperoxaluria managed at a major transplant unit was performed. RESULTS: The 5 patients had a mean age of 32.2 years (range 28-40) at time of first transplantation. 3 patients had kidney only transplants (one live donor, 2 deceased donor) and 2 had segmental liver followed by delayed kidney transplantation. All 3 kidney alone failed and one is now awaiting a live donor transplant, one underwent kidney alone retransplantation (failed 5 years later) and one had a combined deceased donor liver and kidney transplantation (remains well at 4 years). The 2 segmental liver sequential kidney transplant recipients remain well at 1 year and 3 years. CONCLUSIONS: Combined liver-kidney transplantation may be a better choice as the primary transplant procedure. The indication and timing for pre-emptive liver or liver followed by delayed kidney transplantation remains a matter of debate.