Bulletin of The Royal College of Surgeons of England, Nov 1, 2009
There have been many advances in patient care over the past 15 years. Some have been driven by ch... more There have been many advances in patient care over the past 15 years. Some have been driven by changes in technology, some by pharmaceuticals and a better understanding of disease processes, and some by changes to service delivery. The patient remains at the heart of the process, however, and expectations have not stood still. Patients are now better informed and have access to a wealth of information relating both to their condition and its treatment and also to the clinicians who are delivering their care. The NHS has shifted to a market-driven model, in which services and resources are put out to tender and units must function within budgetary constraints.
The switch from time-based to competency-based training has required a more robust method of asse... more The switch from time-based to competency-based training has required a more robust method of assessment, to ensure that speciality trainees are gaining the competencies required in order to progress through their programme. This has resulted in the development of a system of Annual Reviews of Competency Progression (ARCP), which provide a formal review of all aspects of training and, if this is found to be satisfactory, permits progression. Most surgical speciality programmes run the ARCP as a face-to-face meeting, at which the required evidence of training is reviewed via an online portfolio (e-Portfolio); this is managed via the Intercollegiate Surgical Curriculum Project (ISCP) website. The e-Portfolio is therefore clearly a key document and the outcome of each ARCP will largely depend on its content. In addition to the mandatory Workplace Based Assessments (WBAs) and surgical logbook, the portfolio also contains additional records, such as involvement in research and audit and attendance at relevant courses. Success at the ARCP will require a complete set of evidence of acquisition of the mandatory competencies, but will also be greatly enhanced by the demonstration of 'added value'. Trainees are therefore encouraged to strive for excellence throughout their training programme, rather than just adequacy and will be rewarded, not only by success at the ARCP but also by a strong and competitive curriculum vitae. This article describes how to prepare the various components of a portfolio for the ARCP, practical advice of what to expect on the day and, on a more personal level, how to cope if things are not going according to plan.
The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor bloc... more The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri-operative period. This study aimed to investigate if withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers peri-operatively reduces the risk of acute kidney injury following major non-cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi-level models were used to account for centre-level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republi...
and radiological variables to predict survival in all patients with a diagnosis of peri-hilar cho... more and radiological variables to predict survival in all patients with a diagnosis of peri-hilar cholangiocarcinoma. The objective of this study was to evaluate the utility of these models in determining prognosis for all patients presenting to a tertiary treatment centre with PHC. Methods: Three hundred and two patients diagnosed with PHC referred to a regional tertiary referral centre between 2008 and 2019 had their demographic and survival data retrospectively analysed from a prospectively held database linked to Hospital Episode Statistics and Somerset Cancer Registry data. One hundred and twenty seven patients were surgically explored. Eight-four patients underwent resection. One-hundred and seventy-four (57.6%) patients underwent palliative endoscopic therapy. Univariate and multivariate modelling was utilised to determine significant prognostic variables. Concordance Indices (C-Indices) were constructed for the prognostic models to determine internal validity within the cohort. Results: Multivariate analysis demonstrated that: pre-interventional ECOG status (p < 0.001); serum albumin (p < 0.001); bilirubin levels (p < 0.001); CA 19-9 levels (p < 0.001) and resectional status (p < 0.001) were significant predictors of OS. Patients stratified by the MC scoring system to early-stage disease had a significantly longer OS compared to patients fulfilling late-stage criteria (p < 0.001). The predictive C-Indices for the MC model obtained significance in discriminating OS for the entire cohort (p < 0.05) and un-resected patients (p < 0.05). Neither model attained significant concordance for accurately discriminating OS in post-resectional patients. Conclusions: The predictive performance of the stated prognostic models for OS have poor utility. Simple pre-interventional serological, functional and radiological variables appear to provide better prognostic indication of OS. Variables not incorporated in the AJCC registry have a significant effect upon post-resectional OS and require full incorporation in to model prognostication.
Introduction Pre-hospital intubation by paramedics is widely used in comatose patients prior to t... more Introduction Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain. Methods The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients. Results There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital. Conclusions Paramedic RSI in patients with nontraumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.
IntroductionPost-hepatectomy liver failure (PHLF), driven by insufficient volume and quality of t... more IntroductionPost-hepatectomy liver failure (PHLF), driven by insufficient volume and quality of the remnant liver following an operation, is a significant clinical problem that is currently underserved by pre-operative assessment methods. Clinical management and a patient’s recovery from post-operative liver related complications results in a protracted stay in hospital.Methods91 patients with colorectal liver metastasis being considered for liver resection were recruited onto the Precision1 trial. The imaging report from an additional non-quantitative multiparametric MRI (mpMRI) scan was examined and used to alter surgical decision making. Patient outcomes were monitored and evaluated against a standard of care comparator dataset blinded to mpMRI scan results.ResultsPreviously undiagnosed liver disease activity or elevated liver fat was detected using mpMRI in 23% of patients, whereas the liver health was unexpectedly good in 7% of patients; this resulted in a change to surgical pl...
BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...
Background This study aimed to determine the impact of pulmonary complications on death after sur... more Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery be...
Background This study aimed to determine the impact of preoperative exposure to intravenous contr... more Background This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. Methods This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. Results A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) rec...
Introduction: Acute pancreatitis management remains mainly supportive and can be challenging in p... more Introduction: Acute pancreatitis management remains mainly supportive and can be challenging in patients. Aim: Our study aims to describe a 10 years tertiary-center experience in management of acute pancreatitis. Method: Clinical management and outcomes of 300 prospectively enrolled acute pancreatitis patients stratified by the Revised Atlanta Classification were analyzed; trends in management between early (2006-2010) and late enrollment phase (2011-2015) were assessed. Results: 62 % of patients were classified as mild acute pancreatitis; moderately severe and severe grades contained 23.5% and 14.5% of participants. IV administration during the first 24 hours (mild acute pancreatitis 3.7, moderately severe acute pancreatitis 4.7, and severe acute pancreatitis 4.8 L), need for ICU (6%, 13%, 63%), and nutritional support (18%, 70%, 95%) increased significantly with greater acute pancreatitis severity (p < 0.001). 57 (19%) patients developed necrotizing pancreatitis, of which 70% received prophylactic antibiotics, and 21% underwent pancreatic drainage/debridement. Prophylactic antibiotics (95% vs. 70%) and interventions (63% vs. 27%) were noted more frequently in severe acute pancreatitis than moderately severe acute pancreatitis (p < 0.001). Minimally invasive pancreatic interventions (19% vs. 41%) were more commonly used in the late phase (p < 0.05). The overall median length of hospitalization was 11 days reaching 29 days in severe acute pancreatitis group. Mortality was 2%; all deaths occurred in severe acute pancreatitis group. Conclusion: This study shows an extensive report on outcome of acute pancreatitis and its trends overtime. Intervention treatment is required in less than 50% of patients with necrotizing pancreatitis. Utilization of enteral nutrition and minimally invasive pancreatic interventions has been increasing over time.
Background Optimisation of the future liver remnant (FLR) is crucial to the safety of extended li... more Background Optimisation of the future liver remnant (FLR) is crucial to the safety of extended liver resections. This study aimed to assess volume and quality of the FLR pre- and post-dual vein embolisation (DVE) by MRI, in patients with insufficient FLR, needing major hepatectomy. Methods Of 81 patients recruited in a clinical trial (Precision1:NCT04597710), seven consecutive patients with colorectal liver metastases underwent multiparametric MRI (Hepatica®) pre- and post-DVE (right hepatic and portal vein). One patient had DVE after a first-stage hepatectomy. FLR volume, fibro-inflammation map (corrected T1) and fat (proton density fat fraction, PDFF) was determined. Results All 7 patients underwent uncomplicated DVE, with significant increase in median(range) %FLR volume at liver surgery [45.7(27.0–57.8)% versus 32.4 (19.5–37.7)%, p=0.016], 46 days (range 28–77) post-DVE. Median(range) FLR cT1 scores reduced post-DVE [747.33 (684–884)ms, versus 771.25(726–945)ms, p=0.047; healthy...
Background The risk of major haemorrhage during liver surgery has decreased considerably in the m... more Background The risk of major haemorrhage during liver surgery has decreased considerably in the modern era. However, there remains reluctance amongst liver surgeons to give routine peri-operative chemical thromboprophylaxis, either because of the perceived risk of bleeding, or transient post-operative abnormalities in conventional coagulation studies. The aim of this study was to ask whether a defined, homogeneous population of patients undergoing liver resection for colorectal metastases (CRM) were at risk from venous thromboembolism (VTE) prior to surgery, and what the impact of liver resection was on that risk. Methods A single-centre prospective observational cohort study comparing pre-, peri- and post-operative haemostasis variables in patients undergoing liver resection for CRM. Patients with cirrhosis, history of VTE or anticoagulated were excluded, as were patients undergoing small wedge, or laparoscopic liver resections. Blood samples for coagulation assays were collected p...
Introduction Interest in intra-abdominal pressure (IAP) measurement has increased significantly, ... more Introduction Interest in intra-abdominal pressure (IAP) measurement has increased significantly, with evidence of its deleterious effects demonstrated on every organ. Despite the volume of publications – several assumptions relating to the measurement of IAP remain unproven and there is a paucity of data relating to patients in a specialised liver Intensive Therapy Unit (ITU). Methods This thesis encompasses a survey of the available literature and national attitudes / practice with several clinical experiments; Generic Questions 1. IAP measurement technique – validation of current gold-standard against alternatives 2. Identification of potential sources of error in measurement of IAP 3. Impact of body position and zero-reference point on IAP Specialty Specific Questions 1. Incidence of raised IAP in specialised liver ITU and its link to complications / length of stay 2. Identification of early predictors of raised IAP 3. Study of regional abdominal compartmental variation in IAP
Bulletin of The Royal College of Surgeons of England, Nov 1, 2009
There have been many advances in patient care over the past 15 years. Some have been driven by ch... more There have been many advances in patient care over the past 15 years. Some have been driven by changes in technology, some by pharmaceuticals and a better understanding of disease processes, and some by changes to service delivery. The patient remains at the heart of the process, however, and expectations have not stood still. Patients are now better informed and have access to a wealth of information relating both to their condition and its treatment and also to the clinicians who are delivering their care. The NHS has shifted to a market-driven model, in which services and resources are put out to tender and units must function within budgetary constraints.
The switch from time-based to competency-based training has required a more robust method of asse... more The switch from time-based to competency-based training has required a more robust method of assessment, to ensure that speciality trainees are gaining the competencies required in order to progress through their programme. This has resulted in the development of a system of Annual Reviews of Competency Progression (ARCP), which provide a formal review of all aspects of training and, if this is found to be satisfactory, permits progression. Most surgical speciality programmes run the ARCP as a face-to-face meeting, at which the required evidence of training is reviewed via an online portfolio (e-Portfolio); this is managed via the Intercollegiate Surgical Curriculum Project (ISCP) website. The e-Portfolio is therefore clearly a key document and the outcome of each ARCP will largely depend on its content. In addition to the mandatory Workplace Based Assessments (WBAs) and surgical logbook, the portfolio also contains additional records, such as involvement in research and audit and attendance at relevant courses. Success at the ARCP will require a complete set of evidence of acquisition of the mandatory competencies, but will also be greatly enhanced by the demonstration of 'added value'. Trainees are therefore encouraged to strive for excellence throughout their training programme, rather than just adequacy and will be rewarded, not only by success at the ARCP but also by a strong and competitive curriculum vitae. This article describes how to prepare the various components of a portfolio for the ARCP, practical advice of what to expect on the day and, on a more personal level, how to cope if things are not going according to plan.
The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor bloc... more The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri-operative period. This study aimed to investigate if withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers peri-operatively reduces the risk of acute kidney injury following major non-cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi-level models were used to account for centre-level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republi...
and radiological variables to predict survival in all patients with a diagnosis of peri-hilar cho... more and radiological variables to predict survival in all patients with a diagnosis of peri-hilar cholangiocarcinoma. The objective of this study was to evaluate the utility of these models in determining prognosis for all patients presenting to a tertiary treatment centre with PHC. Methods: Three hundred and two patients diagnosed with PHC referred to a regional tertiary referral centre between 2008 and 2019 had their demographic and survival data retrospectively analysed from a prospectively held database linked to Hospital Episode Statistics and Somerset Cancer Registry data. One hundred and twenty seven patients were surgically explored. Eight-four patients underwent resection. One-hundred and seventy-four (57.6%) patients underwent palliative endoscopic therapy. Univariate and multivariate modelling was utilised to determine significant prognostic variables. Concordance Indices (C-Indices) were constructed for the prognostic models to determine internal validity within the cohort. Results: Multivariate analysis demonstrated that: pre-interventional ECOG status (p < 0.001); serum albumin (p < 0.001); bilirubin levels (p < 0.001); CA 19-9 levels (p < 0.001) and resectional status (p < 0.001) were significant predictors of OS. Patients stratified by the MC scoring system to early-stage disease had a significantly longer OS compared to patients fulfilling late-stage criteria (p < 0.001). The predictive C-Indices for the MC model obtained significance in discriminating OS for the entire cohort (p < 0.05) and un-resected patients (p < 0.05). Neither model attained significant concordance for accurately discriminating OS in post-resectional patients. Conclusions: The predictive performance of the stated prognostic models for OS have poor utility. Simple pre-interventional serological, functional and radiological variables appear to provide better prognostic indication of OS. Variables not incorporated in the AJCC registry have a significant effect upon post-resectional OS and require full incorporation in to model prognostication.
Introduction Pre-hospital intubation by paramedics is widely used in comatose patients prior to t... more Introduction Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain. Methods The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients. Results There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital. Conclusions Paramedic RSI in patients with nontraumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.
IntroductionPost-hepatectomy liver failure (PHLF), driven by insufficient volume and quality of t... more IntroductionPost-hepatectomy liver failure (PHLF), driven by insufficient volume and quality of the remnant liver following an operation, is a significant clinical problem that is currently underserved by pre-operative assessment methods. Clinical management and a patient’s recovery from post-operative liver related complications results in a protracted stay in hospital.Methods91 patients with colorectal liver metastasis being considered for liver resection were recruited onto the Precision1 trial. The imaging report from an additional non-quantitative multiparametric MRI (mpMRI) scan was examined and used to alter surgical decision making. Patient outcomes were monitored and evaluated against a standard of care comparator dataset blinded to mpMRI scan results.ResultsPreviously undiagnosed liver disease activity or elevated liver fat was detected using mpMRI in 23% of patients, whereas the liver health was unexpectedly good in 7% of patients; this resulted in a change to surgical pl...
BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointesti... more BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...
Background This study aimed to determine the impact of pulmonary complications on death after sur... more Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery be...
Background This study aimed to determine the impact of preoperative exposure to intravenous contr... more Background This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. Methods This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. Results A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) rec...
Introduction: Acute pancreatitis management remains mainly supportive and can be challenging in p... more Introduction: Acute pancreatitis management remains mainly supportive and can be challenging in patients. Aim: Our study aims to describe a 10 years tertiary-center experience in management of acute pancreatitis. Method: Clinical management and outcomes of 300 prospectively enrolled acute pancreatitis patients stratified by the Revised Atlanta Classification were analyzed; trends in management between early (2006-2010) and late enrollment phase (2011-2015) were assessed. Results: 62 % of patients were classified as mild acute pancreatitis; moderately severe and severe grades contained 23.5% and 14.5% of participants. IV administration during the first 24 hours (mild acute pancreatitis 3.7, moderately severe acute pancreatitis 4.7, and severe acute pancreatitis 4.8 L), need for ICU (6%, 13%, 63%), and nutritional support (18%, 70%, 95%) increased significantly with greater acute pancreatitis severity (p < 0.001). 57 (19%) patients developed necrotizing pancreatitis, of which 70% received prophylactic antibiotics, and 21% underwent pancreatic drainage/debridement. Prophylactic antibiotics (95% vs. 70%) and interventions (63% vs. 27%) were noted more frequently in severe acute pancreatitis than moderately severe acute pancreatitis (p < 0.001). Minimally invasive pancreatic interventions (19% vs. 41%) were more commonly used in the late phase (p < 0.05). The overall median length of hospitalization was 11 days reaching 29 days in severe acute pancreatitis group. Mortality was 2%; all deaths occurred in severe acute pancreatitis group. Conclusion: This study shows an extensive report on outcome of acute pancreatitis and its trends overtime. Intervention treatment is required in less than 50% of patients with necrotizing pancreatitis. Utilization of enteral nutrition and minimally invasive pancreatic interventions has been increasing over time.
Background Optimisation of the future liver remnant (FLR) is crucial to the safety of extended li... more Background Optimisation of the future liver remnant (FLR) is crucial to the safety of extended liver resections. This study aimed to assess volume and quality of the FLR pre- and post-dual vein embolisation (DVE) by MRI, in patients with insufficient FLR, needing major hepatectomy. Methods Of 81 patients recruited in a clinical trial (Precision1:NCT04597710), seven consecutive patients with colorectal liver metastases underwent multiparametric MRI (Hepatica®) pre- and post-DVE (right hepatic and portal vein). One patient had DVE after a first-stage hepatectomy. FLR volume, fibro-inflammation map (corrected T1) and fat (proton density fat fraction, PDFF) was determined. Results All 7 patients underwent uncomplicated DVE, with significant increase in median(range) %FLR volume at liver surgery [45.7(27.0–57.8)% versus 32.4 (19.5–37.7)%, p=0.016], 46 days (range 28–77) post-DVE. Median(range) FLR cT1 scores reduced post-DVE [747.33 (684–884)ms, versus 771.25(726–945)ms, p=0.047; healthy...
Background The risk of major haemorrhage during liver surgery has decreased considerably in the m... more Background The risk of major haemorrhage during liver surgery has decreased considerably in the modern era. However, there remains reluctance amongst liver surgeons to give routine peri-operative chemical thromboprophylaxis, either because of the perceived risk of bleeding, or transient post-operative abnormalities in conventional coagulation studies. The aim of this study was to ask whether a defined, homogeneous population of patients undergoing liver resection for colorectal metastases (CRM) were at risk from venous thromboembolism (VTE) prior to surgery, and what the impact of liver resection was on that risk. Methods A single-centre prospective observational cohort study comparing pre-, peri- and post-operative haemostasis variables in patients undergoing liver resection for CRM. Patients with cirrhosis, history of VTE or anticoagulated were excluded, as were patients undergoing small wedge, or laparoscopic liver resections. Blood samples for coagulation assays were collected p...
Introduction Interest in intra-abdominal pressure (IAP) measurement has increased significantly, ... more Introduction Interest in intra-abdominal pressure (IAP) measurement has increased significantly, with evidence of its deleterious effects demonstrated on every organ. Despite the volume of publications – several assumptions relating to the measurement of IAP remain unproven and there is a paucity of data relating to patients in a specialised liver Intensive Therapy Unit (ITU). Methods This thesis encompasses a survey of the available literature and national attitudes / practice with several clinical experiments; Generic Questions 1. IAP measurement technique – validation of current gold-standard against alternatives 2. Identification of potential sources of error in measurement of IAP 3. Impact of body position and zero-reference point on IAP Specialty Specific Questions 1. Incidence of raised IAP in specialised liver ITU and its link to complications / length of stay 2. Identification of early predictors of raised IAP 3. Study of regional abdominal compartmental variation in IAP
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