Category Archives: Hepato-Biliary-Pancreatic

Post-pancreatectomy haemorrhage management stratified according to ISGPS grading

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“Despite improvements in the perioperative care of patients undergoing pancreatic surgery, the risk of major complications including anastomotic leak (6–24%), post-operative pancreatic fistula (POPF) (10–40%) and delayed gastric emptying (20–34%) persist. Post-pancreatectomy haemorrhage (PPH) is a less common, but particularly hazardous complication with mortality rates of up to 40%. However, varying definitions and incidences of PPH have been previously reported, which have hindered comparison of optimal treatment modalities.”

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Perioperative protocol for pancreatic resections in patients who refuse blood transfusions.

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“The refusal of blood transfusion for surgical procedures at high risk of bleeding, such as pancreatic resection, forces surgeons to face ethical challenges and raises concerns about appropriate perioperative management. In the last two decade the rate of transfusion in high volume centers has gradually decreased thanks to the application of patient blood management (PBM) protocols.”

“In our single-institution experience, patients that categorically refused transfusion were Jehovah’s Witnesses (JW). JW is a religious movement, membership in which accounts for about 0.3% of Western countries’ populations, with USA and Italy having the highest percentages of followers. JW followers believe neither whole blood nor its four major components, namely red cells, white cells, platelets and plasma, should be donated, stored, or accepted in any circumstance, even in life-threatening situations. Advances in transfusion medicine have led the JW’s denomination to modify its position about what is deemed acceptable.”

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Transjugular intrahepatic portosystemic shunt before abdominal surgery in cirrhotic patients

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“Abdominal surgery is occasionally needed in cirrhotic patients and is associated with high morbidity and mortality rates. It has been suggested that the main determinant of short- and long-term survival is the degree of liver failure, as evaluated by the presence of ascites, low serum albumin level and coagulation disorders. In addition, the degree of portal
hypertension may be an independent predictor for operative bleeding, postoperative ascites leakage or variceal rupture; this may also influence survival. Transjugular intrahepatic portosystemic shunt (TIPS) placement is much less invasive than surgical shunts and can be performed in patients with a significant degree of liver insufficiency. Therefore, it has been suggested that preoperative TIPS placement may improve the prognosis of cirrhotic patients, submitted to abdominal surgery.”

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Hypoglycemia associated with renal failure

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“Hypoglycemia associated with renal failure is more common than generally thought. Its occurrence is often a marker of multisystem failure and has an ominous prognostic implication. Its pathogenesis is frequently complex and involves one or several mechanisms. In the evaluation of uremic hypoglycemia, the first step should be the exclusion of obvious causes such as insulin, oral hypoglycemic agent therapy, and the use of drugs known to cause hypoglycemia. Propranolol, salicylates, and disopyramide are among the most commonly implicated agents.”

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Laparoscopic Entry Techniques and Injuries

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“Recent reports by the Australian Safety and Efficacy Register for New interventions and Procedures (ASERNIP-S) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) concluded that insufficient evidence is available to assess the safety of the open versus closed laparoscopy in regard to major vascular and visceral injuries.” (Larobina & Nottle)

Major Vascular Injuries in Closed vs. Open Laparoscopy (Larobina & Nottle)

“Our case series shows that open laparoscopy can vastly reduce the incidence of access-related morbidity and mortality. Only a single visceral injury occurred in 5900 cases, and no major vascular injuries were reported.These figures are consistent with those of other reported series of open laparoscopy, which also show a zero rate of vascular injury and low rates of visceral injury.The literature review showed a rate of 1 injury to major retroperitoneal vessels per 2272 cases of closed laparoscopy procedures. This compares with a major vascular injury rate of 0 for the open technique. This difference is both statistically significant ( P = 0.003) and highly clinically significant.” (Larobina & Nottle)

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Management of pancreatic pseudocysts

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“Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers.”

“ Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.”

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Pancreatic necrosis

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“Pancreatic necrosis is the most devastating complication of acute pancreatitis. Management of this complex disease has improved dramatically over the past decade, and mortality rates are regularly reported in the range of 20% instead of the 50% to 70% range reported in the 1970s. Despite this improvement, 80% of deaths from acute pancreatitis evolve from infectious complications of pancreatic and peripancreatic necrosis.”

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