Sandie Thomson

Preoperative imaging of pancreatic cancer: a management-oriented approach.

Imaging of pancreatic cancer involves both diagnosis and staging of the tumor. Accurate diagnosis allows the clinician to be frank with the patient and eliminates anxiety and uncertainty associated with a pancreatic lesion of unknown etiology. Accurate staging should facilitate clinical decision making and limit surgery to those who would benefit from laparotomy. Imaging includes nonoperative techniques, such as abdominal ultrasonography, CT scan, MRI, and angiography and a variety of invasive techniques, such as laparoscopy and laparoscopic or intraoperative ultrasonography. Operative imaging complements nonoperative imaging but is outside the scope of this article. The algorithm for use of nonoperative imaging techniques needs to be clearly defined, because rapid technologic development has resulted in increasing costs and a degree of confusion among clinicians. Recent reviews have focused on diagnosis of early pancreatic cancer in high-risk patients using a combination of biochemical markers and imaging or technical aspects of current imaging techniques without attempting to integrate them into a flexible management algorithm that can be tailored to the individual patient. This article attempts to relate these investigations directly to individual patient management. So patient factors, such as the need to assess stage, and establish a tissue diagnosis in certain categories of patient, factor into the choice of appropriate investigations. The importance of the clinical examination cannot be understated. This has two objectives: to assess fitness for operation and to detect evidence of metastatic disease. If the patient is not fit enough to withstand abdominal surgery or has diffuse metastatic disease, surgery is contraindicated and more thorough investigation is not warranted. The presence of supraclavicular or umbilical nodes, peritoneal carcinomatosis on rectal examination, or ascites can provide evidence of diffuse malignant disease. It is a simple matter to confirm this with a lymph node biopsy or an ascitic tap. Clinically apparent disseminated disease is a contraindication to pancreatic resection because of its abysmal prognosis. But in the absence of signs, the clinician relies on imaging techniques to stage the disease.

Selective Conservatism in Trauma Management: A South African Contribution

Trauma in South Africa has been termed the malignant epidemic [1]. This heritage was the result of a violent colonial legacy [2] which spawned the apartheid system of injustice and the struggle against it [3,4] The Apartheid regime created overcrowding, unemployment, social stagnation, and the disruption of normal family life. These were the catalysts for the incredible amount of criminal and interpersonal conflict in South Africa over the last 50 years. African townships such as Soweto in Johannesburg and Umlazi in Durban were crime-ridden ghettoes where the apartheid police were more interested in fueling the ‘‘black on black’’ violence rather than trying to curb it. Baragwanath (Chris HaniBaragwanath) and King Edward the VIII Hospital in Durban were the ‘‘trauma care epicenters’’ on the fringes of these huge urban conurbations. Both were designated black hospitals and both were underfunded and dilapidated. Even the architecture was similar, with prefabricated, poorly ventilated structures serving as wards and clinics in both institutions. Trauma volumes consisted of between 10 and 20 laparotomies on weekend nights at the height of political unrest. This led to vast individual experience in several areas of trauma typified by Demetriades experience with 70 penetrating cardiac injuries [5]. In this setting of limited resources and an overwhelming volume of trauma, selective conservatism as a surgical philosophy took root and has profoundly influenced the way the world manages trauma. We detail and illustrate the evolution of this approach and its continued application. Selective conservatism is not a new concept. By necessity in the pre-anaesthetic era it was practiced for centuries with few survivors [6]. It was called into question only in the late 19th century and early 20 century when the mass casualties of modern warfare and advances in surgical and anaesthetic techniques swung the pendulum to an operative approach. This dominated surgical practice until the 1960s 5 when Shaftan [7,8] reintroduced the concept and described the successful nonoperative management of penetrating abdominal wounds. Both well-funded and resource-poor centers, some dealing with high volumes of blunt and penetrating trauma, now advocate this policy [9–14]. What does selective conservatism mean? It has more facets than simply not operating on selected individuals. The primary elements are clinical observation and re-evaluation. The first decision point is whether to intervene or continue observation and investigation. This decision is tempered by the knowledge that an intervention, either diagnostic or therapeutic, may do more harm than good. Therefore, the question must be: Is an intervention truly necessary? If the answer is yes then we need to decide what intervention is appropriate and whether a simple option would suffice instead of a complex operation. We ask these questions on a daily basis and they remain the key elements of this approach. This has generated observational studies, retrospective audits, prospective audits, and comparative studies. We present some of these to illustrate and substantiate the value of this approach in different anatomical regions and how it has developed with emerging technology. Until the mid-1980s these studies were based almost exclusively on injuries inflicted by stab wounds. Since then there has been a significant change in the nature of penetrating trauma in South Africa as typified by the reports from clinical and forensic audits [15, 17–17]. From 1983 to 1992 [15] 2500 penetrating torso injuries were treated annually. Over that decade stab wounds declined by 30% but firearm wounds increased by 873% with a mortality rate of 1.6% for stabs and 12.5% for firearms. This has prompted us to review our approach to these problems to see if the principles of selective conservatism need to be modified when applied to firearm injuries. Penetrating Neck Trauma The high concentration and intimate relationship of vital structures in the neck meant that most surgeons felt that exploration was mandatory for any injury that penetrated the platysma muscle. The natural history and the results of a selective policy were documented at Baragwanath [18]. In 1980 [19] over a six-month period 108 patients admitted to King Edward the VIII were prospectively evaluated. Exploration was undertaken only for hard clinical or radiologic signs of vascular or aerodigestive injury. Only 26 were explored of whom two died. In the conservative group one died from an associated thoracic injury. This concept of nonoperative management was again analyzed in a cohort of Correspondence to: S. R. Thomson, ChM, FRCS (Ed and Eng), e-mail: Thomson@ukzn.ac.za World J. Surg. 29, 962–965 (2005) DOI: 10.1007/s00268-005-0131-9

An audit of failed non-operative management of abdominal stab wounds.

UNLABELLEDnSelective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures.nnnMETHODSnThe metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time.nnnRESULTSnA total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3).nnnCONCLUSIONnClinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.

A Single Surgical Unit’s Experience with Abdominal Tuberculosis in the HIV/AIDS Era

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has resulted in a resurgence of abdominal tuberculosis in South Africa, and these patients often present to general surgeons. We describe a single-hospital experience in a region of high HIV prevalence. A prospective database of all patients with suspected abdominal tuberculosis was maintained from January 2003 until July 2005. There were 67 patients (20 men, 47 women) with an average age of 32 years (range 27–61 years). The erythrocyte sedimentation rate was universally elevated (105xa0±xa023). Altogether, 23 patients were HIV-positive and 7 were HIV-negative. The status was unknown in the remainder. Chest radiographs demonstrated an abnormality in 17 patients (22%). Abdominal ultrasonography was performed in 59 patients and computed tomography in 12. Twelve laparotomies were performed, seven as emergencies. None in the elective laparotomy group died, whereas the mortality rate in the emergency group was 60%. Laparoscopy was insufficient for a variety of reasons. Two patients underwent appendectomy and two excision of a perianal fistula. Two patients underwent biopsy of a palpable subcutaneous node, which confirmed the diagnosis in both cases. A definitive diagnosis was achieved in all 12 patients subjected to laparotomy and at colonoscopic biopsy in 2, lymph node biopsy in 2, appendectomy in 2, perianal fistulectomy in 2, and percutaneous drainage in 2. In the remaining 47 patients the diagnosis was made on the basis of the clinical presentation and radiologic imaging. The patients were commenced on antituberculous therapy. The in-hospital mortality in this group was 10%. Therapy was continued at a centralized tuberculosis facility independent of the hospital. Surgical follow-up was poor, with only five (7%) patients completing the 6-month review at a surgical clinic. A resurgence in tuberculosis during the HIV era produces a new spectrum of presentations for the surgeon. Emergency surgery is associated with high mortality. Bacterial and histologic evidence of infection are difficult to obtain, and indirect clinical and imaging evidence are used to commence a trial of therapy. A short-term clinical response is regarded as proof of disease. Lack of follow-up means that the efficacy of this strategy is unproven. Health policy changes are needed to enable appropriate surgical follow-up to determine the most effective management algorithm.

Double jeopardy revisited: Clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

INTRODUCTIONnIn the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.nnnMETHODSnAll stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.nnnRESULTSnSixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.nnnCONCLUSIONnIncorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.

The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education.

INTRODUCTIONnThis audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs.nnnMETHODSnAt a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors.nnnRESULTSnDuring the period July 2009-2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3).nnnCONCLUSIONSnRural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma.

Using a Hybrid Electronic Medical Record System for the Surveillance of Adverse Surgical Events and Human Error in A Developing World Surgical Service

AbstractIntroductionnThe quantification and analysis of adverse events is essential to benchmark surgical outcomes and establish a foundation for quality improvement interventions. We developed a hybrid electronic medical record (HEMR) system for the accurate collection and integration of data into a structured morbidity and mortality (M&M) meeting.MethodologynThe HEMR system was implemented on January 1, 2013. It included a mechanism to capture and classify adverse events using the ICD-10 coding system. This was achieved by both prospective reporting by clients and by retrospective sentinel-event-trawling performed by administrators.ResultsFrom January 1, 2013 to March 20, 2014, 6,217 patients were admitted within the tertiary surgical service of Greys Hospital. A total of 1,314 (21.1xa0%) adverse events and 315 (5.1xa0%) deaths were recorded. The adverse events were divided into 875 “pathology-related” morbidities and 439 “error-related” morbidities. Pathology-related morbidities included 725 systemic complications and 150 operative complications. Error-related morbidities included 257 cognitive errors, 158 (2.5xa0%) iatrogenic injuries, and 24 (1.3xa0%) missed injuries. Error accounted for 439 (33xa0%) of the total number of adverse events. A total of 938 (71.4xa0%) adverse events were captured prospectively, whereas the remaining 376 (28.6xa0%) were captured retrospectively. The ICD-10 coding system was found to have some limitations in its classification of adverse events.ConclusionsThe HEMR system has provided the necessary platform within our service to benchmark the incidence of adverse events. The use of the international ICD-10 coding system has identified some limitations in its ability to classify and categorise adverse events in surgery.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification

AIM To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries. METHODS A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied. RESULTS Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. CONCLUSION This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.