Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

“Acute kidney injury (AKI) is a common complication following major abdominal surgery and is associated with increased length of hospital stay, the progression of chronic kidney disease (CKD), and increased long-term mortality. The rate of AKI amongst patients within different enhanced recovery programs (ERP) is reported to be between 3 and 23%. Patient-related risk factors for AKI include age, comorbidities such as hypertension and diabetes, a history of CKD, and use of angiotensin-converting enzyme inhibitors. Procedure-related factors that may impact on the prevalence of AKI include open surgery, the requirement for blood products, the use of intraoperative vasopressors, and a restrictive perioperative fluid regimen. The original guidelines published by the Enhanced Recovery After Surgery (ERAS) Society for colorectal surgery (CRS) as well as their recent update (2018 guidelines) promote a number of measures which aim to maintain near euvolaemia such as preoperative carbohydrate loading, avoidance of bowel preparation, minimisation of fasting times, minimally invasive surgery, and early resumption of oral fluid therapy.”

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ACG Clinical Guideline: Focal Liver Lesions

“With the continued dramatic rise in the widespread role of imaging in diagnosis and management of patients, there is a resultant rise in detection of asymptomatic incidental liver lesions. Common imaging modalities in which incidental liver lesions are detected include ultrasonography (US) with or without contrast agent (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI) for abdominal or nonabdominal indications (breast and spine). Studies show a continued upward trend in utilization of CT/MRI/US imaging in adults in the United States and Canada, inevitably resulting in increased detection of incidental FLLs within the liver. In fact, some studies show that up to 52% of patients without cancer have a benign liver lesion at autopsy. The American College of Radiology reports that up to 15% of patients have an incidental liver lesion detected
on routine nonsurveillance imaging. Therefore, it is critical to understand appropriate management of incidentally detected benign FLLs because they have differing clinical implications from malignant lesions such as hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), and metastatic disease.”

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Long-term outcomes after extrahepatic excision of congenital choladocal cysts

“Congenital choladocal cysts are generally treated by resection of the dilated extrahepatic biliary duct followed by hepaticojejunostomy, but it is associated with postoperative complications, including postoperative cholangitis, intrahepatic calculi, pancreatitis, and carcinogenesis, in the remnant bile duct. We investigated the most common long-term complications and identified the factors implicated in their development.”

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Pancreatitis after Biliary Tract Surgery (Historical article)

“Acute pancreatitis after operation on the biliary tract is a serious complication. This study was undertaken in an attempt to determine predisposing factors which might exist in patients undergoing operation for biliary tract disease. A large number of patients have been studied by postoperative serum amylase determinations and correlations have been made between the performance of various procedures and the occurrence of clinical and subclinical pancreatitis.”

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Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS)

“Liver resection is used increasingly for the management of a variety of benign and malignant conditions. These data have paralleled substantial advances in perioperative management and operative techniques that have improved the safety of, and extended the indications for, liver resection over the past 2 decades. Extended liver resections, liver resections in diseased liver or liver parenchyma affected by chemotherapy, and repeat
or staged liver resections are being used to achieve curative resection and extend long-term survival. The resulting small functional remnant liver volumes and compromised liver function in these patients increase the risk for the development of posthepatectomy liver failure (PHLF). Despite the introduction of functional and imaging measures to assess preoperatively the size and function of the future liver remnant, as well as the use of
portal vein embolization as a preventive intervention, PHLF remains a major concern and has been shown to be a predominant cause of hepatectomy-related mortality.”

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Implications of leukocytosis following distal pancreatectomy splenectomy (DPS) and association with postoperative complications

“Distal pancreatectomy with splenectomy (DPS) is performed to remove pathology of the body and/or tail of the pancreas. The spleen and the left side of the pancreas share blood supply, and often tumor involvement, thus splenectomy is often performed along with distal
pancreatectomy. DPS is an operation that carries a greater than 30% risk of postoperative complications, including infection, postoperative pancreatic fistula (POPF), intraabdominal abscesses, and pneumonia, among others. In addition to these immediate postoperative
complications, splenectomy itself is known to confer long‐term susceptibility to infection, sepsis, thrombosis, and other sequelae. Our goal was to identify factors that could prompt early investigation and treatment of both infectious and major complications.”

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Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT)

“Resections of the pancreas reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are done electively (84%) as a result of chronic pancreatitis (24%), other benign diseases (22%), malignant diseases (18%), neuroendocrine tumours (14%), and pancreatic pseudocysts (6%). The remaining 16% are emergency cases after abdominal trauma or miscellaneous pathological
diagnoses. A systematic review supports the evidence that postoperative pancreatic fistula formation represents a major source of postoperative morbidity (13–64%) and is associated with several further complications, such as intra-abdominal abscess, wound infection, sepsis, malabsorption, and haemorrhage.
A meta-analysis of the most favoured and reported techniques (stapler trans-section and closure vs scalpel trans-section and hand-sewn closure of the pancreatic remnant) did
not define the optimum surgical technique of pancreatic stump closure. Therefore, the multicentre randomised DISPACT trial was designed to assess the effect of stapler
versus hand-sewn closure on formation of postoperative pancreatic fistula after distal pancreatectomy.”

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