Christos Skouras

Prostaglandin E2 constrains systemic inflammation through an innate lymphoid cell–IL-22 axis

A prostaglandin barrier to inflammation Blood-borne bacterial infections and severe trauma can send the immune system into overdrive, causing it to pump out inflammatory mediators, sometimes at lethal doses. Duffin et al. now report on a role for prostaglandins in keeping systemic inflammation in check. Systemic inflammation correlates with decreased production of the prostaglandin E2 (PGE2). Blocking PGE2 signaling in mice led to severe inflammation associated with the translocation of gut bacteria. PGE2 acts on innate lymphoid cells, which produce interleukin-22, a secreted protein that helps promote intestinal integrity. Science, this issue p. 1333 Prostaglandin E2 prevents systemic inflammation by maintaining gut barrier integrity. Systemic inflammation, which results from the massive release of proinflammatory molecules into the circulatory system, is a major risk factor for severe illness, but the precise mechanisms underlying its control are not fully understood. We observed that prostaglandin E2 (PGE2), through its receptor EP4, is down-regulated in human systemic inflammatory disease. Mice with reduced PGE2 synthesis develop systemic inflammation, associated with translocation of gut bacteria, which can be prevented by treatment with EP4 agonists. Mechanistically, we demonstrate that PGE2-EP4 signaling acts directly on type 3 innate lymphoid cells (ILCs), promoting their homeostasis and driving them to produce interleukin-22 (IL-22). Disruption of the ILC–IL-22 axis impairs PGE2-mediated inhibition of systemic inflammation. Hence, the ILC–IL-22 axis is essential in protecting against gut barrier dysfunction, enabling PGE2-EP4 signaling to impede systemic inflammation.

Preventing intraperitoneal adhesions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats

OBJECTIVES The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats. METHODS Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons. RESULTS The adhesion scores (mean +/- standard deviation) for groups 1, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively). CONCLUSIONS These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats.

Is there any role for resuscitative emergency department thoracotomy in blunt trauma

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there is any role for resuscitative emergency department thoracotomy in severe blunt trauma. Emergency thoracotomy is an accepted intervention for patients with penetrating cardiothoracic trauma. However, its role in blunt trauma has been challenged and has been a subject of considerable debate. Altogether, 186 relevant papers were identified, of which 14 represented the best evidence to answer the question. The author, journal, date, country of publication and relevant outcomes are tabulated. The 14 studies comprised 2 systematic reviews and 12 retrospective studies. The systematic review performed by the Trauma Committee of the American College of Surgeons included 42 studies and a cumulative total of 2193 blunt trauma patients who underwent an emergency department thoracotomy, reporting a survival rate of 1.6%. According to this review, 15% of the survivors suffered from neurological sequelae, but survivors from both penetrating and blunt trauma were included. A systematic review comprising 24 studies reported a survival rate of 1.4% among 1047 blunt trauma patients. Of the retrospective studies, 11 report poor survival rates, ranging from 0 to 6%. Only one study reports a higher survival rate (12.2%). Five of the studies reported on the neurological outcome of survivors. The majority of the studies suffered from limitations due to the small number of included cases. The reported survival after an emergency department thoracotomy for blunt trauma is very low in the vast majority of available studies. Furthermore, the neurological sequelae in the few survivors are frequent and severe. Interestingly, some author groups recommend that emergency department thoracotomy should be contraindicated in cases of blunt trauma with no signs of life at the scene of trauma or on arrival at the emergency department. Larger, well-designed series will be required to reach a consensus on valid prognostic factors and specific subgroups of blunt trauma patients with substantial chances of survival.

Quality review of an adverse incident reporting system and root cause analysis of serious adverse surgical incidents in a teaching hospital of Scotland

BackgroundA significant proportion of surgical patients are unintentionally harmed during their hospital stay. Root Cause Analysis (RCA) aims to determine the aetiology of adverse incidents that lead to patient harm and produce a series of recommendations, which would minimise the risk of recurrence of similar events, if appropriately applied to clinical practice. A review of the quality of the adverse incident reporting system and the RCA of serious adverse incidents at the Department of Surgery of Ninewells hospital, in Dundee, United Kingdom was performed.MethodsThe Adverse Incident Management (AIM) database of the Department of Surgery of Ninewells Hospital was retrospectively reviewed. Details of all serious (red, sentinel) incidents recorded between May 2004 and December 2009, including the RCA reports and outcomes, where applicable, were reviewed. Additional related information was gathered by interviewing the involved members of staff.ResultsThe total number of reported surgical incidents was 3142, of which 81 (2.58%) cases had been reported as red or sentinel. 19 of the 81 incidents (23.4%) had been inappropriately reported as red. In 31 reports (38.2%) vital information with regards to the details of the adverse incidents had not been recorded. In 12 cases (14.8%) the description of incidents was of poor quality. RCA was performed for 47 cases (58%) and only 12 cases (15%) received recommendations aiming to improve clinical practice.ConclusionThe results of our study demonstrate the need for improvement in the quality of incident reporting. There are enormous benefits to be gained by this time and resource consuming process, however appropriate staff training on the use of this system is a pre-requisite. Furthermore, sufficient support and resources are required for the implementation of RCA recommendations in clinical practice.

Laparoscopic Management of Spigelian Hernias

Purpose Spigelian hernias are rare, and their treatment has traditionally been by open surgery. Laparoscopic management is however, becoming more popular. The aim of our review is to examine the existing evidence regarding the safety and effectiveness of the laparoscopic approach to the management of spigelian hernias. Methods A systematic literature search was carried out including Medline with PubMed as the search engine, and Ovid, Embase, Cochrane Collaboration, and Google Scholar databases to identify articles in English language reporting on laparoscopic management of spigelian hernias. Results Thirty-three articles were found, with a total number of 84 successfully managed cases, reported from 1992 to 2009. No recurrences (0%) and minimal morbidity (2.3%) are reported. Furthermore, the reported hospital stay of patients was remarkably short. Conclusions Current data suggest that the laparoscopic approach to the management of spigelian hernias is safe and effective, both in the elective and emergency setting.

Idiopathic spontaneous haemoperitoneum due to a ruptured middle colic artery aneurysm

INTRODUCTION Idiopathic spontaneous intra-abdominal haemorrhage is a rare, but challenging condition, associated with high mortality if not managed appropriately. The preoperative diagnosis is difficult, despite the recent advances in imaging. We present the clinical manifestations of this condition, as well as the available diagnostic and therapeutic modalities. PRESENTATION OF CASE We report a case of a spontaneously ruptured dissecting aneurysm of the middle colic artery, which was managed with an emergency laparotomy and aneurysmatectomy. Interestingly, no evidence of vasculitis, infection or collagen disease was discovered during the histopathology examination of the specimen. DISCUSSION The treatment of idiopathic spontaneous intra-abdominal haemorrhage revolves around patient resuscitation and management of the source of bleeding. In case of a ruptured aneurysm of the middle colic artery, the surgical management includes emergency laparotomy, arterial ligation and resection of the aneurysm. Transarterial embolisation has been suggested as a safe and less invasive alternative approach. CONCLUSION A ruptured middle colic artery aneurysm should be included in the differential diagnosis of any unexplained intra-abdominal haemorrhage. Aneurysmatectomy is the treatment of choice, with radiologic interventional techniques gaining ground in the management of this entity.

Identifying risk factors for progression to critical care admission and death among individuals with acute pancreatitis: a record linkage analysis of Scottish healthcare databases

Objectives Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP. Setting Health boards in Scotland (n=4). Participants We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP. Methods Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death. Results 2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30–39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission. Conclusions National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high.

Laparoscopic management for carcinoid metastasis to the spleen.

We report a rare case of a laparoscopic splenectomy performed for a carcinoid metastasis. The patient represented with pleuritic left-sided chest pain from pleural deposits 9 years following resection of a primary lung carcinoid tumour. They were found to have a 4.7 cm splenic lesion on CT with a probable left acetabular metastasis demonstrated on Gallium PET scan. The patient underwent laparoscopic splenectomy for debulking treatment of the splenic lesion that was confirmed to be a splenic metastasis of the resected carcinoid lung tumour. Following an uncomplicated recovery, the patient was discharged on the second postoperative day. On discharge, she received adjuvant therapy with Lutetium 177 DOTATATE. This is the first report of a carcinoid splenic metastasis successfully treated with laparoscopic splenectomy.

Early organ dysfunction affects long-term survival in acute pancreatitis patients.

BACKGROUND The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown. OBJECTIVE The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP. METHODS A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan-Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Coxs proportional hazards methods. RESULTS A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4-10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2-11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72-2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048). CONCLUSIONS Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies.

Does laparoscopic Heller’s myotomy provide superior results compared to endoscopic dilatation for oesophageal achalasia?

A best evidence topic was written according to a structured protocol. In [patients with primary oesophageal achalasia] is [laparoscopic Heller Myotomy] superior to [endoscopic dilatation] with respect to [clinical outcomes]. In total 49 papers were found using the reported search, and eight of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that LHM is associated with improved post-operative symptoms and reduced clinical relapse rates compared to ED. Satisfactory clinical outcomes with ED often require repeat procedures performed over time and are associated with an increased risk of oesophageal perforation compared to LHM. One prospective randomized study showed no significant difference in post-operative outcomes between LHM and ED but this was limited by lack of standardization in the endoscopic dilatation procedure, limited reporting of complications and poor long-term follow up. Current evidence shows oesophageal perforation during LHM may be successfully managed intra-operatively but in ED usually requires further laparoscopic or open operative intervention. Fundoplication during LHM is associated with reduced incidence of post-operative gastro-oesophageal reflux disease. There is an increased risk of clinical relapse regardless of the treatment in patients with a sigmoid-shaped oesophagus or reduced oesophageal sphincter pressure assessed during pre-treatment manometry. Current studies are limited by study design, variations in operative technique and dilatation regimens, and limited follow up times. Further higher power studies matching patients for disease severity and surgical technique with longer follow up may enable greater understanding of differences in outcomes and improved patient selection for different treatment regimens.