U.K. Kotze

Variceal Recurrence, Rebleeding, and Survival After Endoscopic Injection Sclerotherapy in 287 Alcoholic Cirrhotic Patients With Bleeding Esophageal Varices

Objective:This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. Summary Background Data:Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. Methods:Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24–87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. Results:Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1–174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3–198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. Conclusion:Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.

Surgical management and outcome of civilian gunshot injuries to the pancreas

Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds.

Prognostic factors, morbidity and mortality in pancreatic trauma: a critical appraisal of 432 consecutive patients treated at a Level 1 Trauma Centre.

BACKGROUND This large retrospective observational cohort study evaluated prognostic factors, 30-day morbidity and mortality and complications related to the pancreas in patients who had sustained pancreatic injuries. METHODS The records of 432 consecutive patients treated for pancreatic injuries at an urban Level 1 Trauma Centre in Cape Town between January 1982 and December 2012 were reviewed. Primary endpoints were postoperative morbidity and death. Bivariate and multivariate logistic regression analyses were used to assess significant predictors of morbidity and mortality. RESULTS Overall mortality in 432 patients [394 men, median age 26, median RTS 7.8] was 15.7% and morbidity 66%. Bivariate logistic regression analysis showed that nine factors, age, RTS, presence of shock, need for a transfusion, volume of blood transfused, damage control surgery, AAST grade of pancreatic injury, an associated vascular injury and a repeat laparotomy were significant predictors of morbidity. In the final multivariate logistic regression analysis model however only two variables, AAST grade of pancreatic injury and a repeat laparotomy were significant predictors of morbidity. When factors associated with mortality were considered, logistic regression analysis found that 11 variables, age, RTS, the presence of shock, patients who required a major blood transfusion, the median number of units transfused, the need for a damage control laparotomy, AAST grade 3, 4, 5 pancreatic injuries, associated vascular injuries, the number of associated injuries, postoperative complications and days in ICU were significant. However in the final stepwise multivariate logistic regression analysis model only five variables, age, shock, median number of units transfused and the presence of associated complications were significant factors associated with mortality. CONCLUSIONS Morbidity was 64% and AAST grade of pancreatic injury and a repeat laparotomy were significant predictors of morbidity. Overall mortality was 15.7%. Most deaths were due to associated injuries and were unrelated to the pancreatic injury. Five variables, age, shock, median number of units transfused and the presence of associated complications were significant factors associated with mortality. These data indicate that the magnitude of blood loss and haemorrhagic shock are primary determinants for survival and that urgent reversal of shock and control of bleeding are essential to reduce mortality in this cohort of patients.

Morbidity and mortality after distal pancreatectomy for trauma: A critical appraisal of 107 consecutive patients undergoing resection at a Level 1 Trauma Centre

BACKGROUND This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy. STUDY DESIGN Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien-Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. RESULTS A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n=26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14±39.4 days. CONCLUSIONS Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien-Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II-IV injuries (p<0.05).

Isolated pancreatic injuries: an analysis of 49 consecutive patients treated at a level 1 trauma centre

BACKGROUND This study interrogated a large prospectively documented institutional database to determine morbidity and mortality after an isolated pancreatic injury (IPI). METHOD Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. The degree of the pancreatic duct injury was graded using a modified Takishima duct injury classification. Primary endpoints were general and pancreas-specific morbidity and mortality. RESULTS Four hundred and forty-eight consecutive patients were treated between 1990 and 2014 for pancreatic injuries of whom 49 (median age: 30, range: 13-68 years, 41 men, blunt injuries: n=43) had an IPI. Thirty-four (70%) patients underwent urgent surgery, 20 of whom had a distal pancreatectomy and 14 had external drainage of the pancreatic injury. Fifteen (30%) patients presented with a non-resolving pancreatic pseudocyst or fistula; five had grade 4A or 4B ductal injuries and underwent surgery, 10 with 3A and 3B ductal injuries were successfully managed endoscopically. Fifty-five percent had postoperative morbidity. Two patients (4%) died of non-pancreatic-related causes. CONCLUSION While overall mortality is low after an IPI, morbidity is high. Two thirds of patients required operative intervention and one third were treated endoscopically. The degree of pancreatic ductal injury determined whether endoscopic intervention was effective.

Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre

BACKGROUND This study evaluated the efficacy of endoscopic treatment of delayed local complications including pseudocysts and persistent pancreatic fistulae in a cohort of civilian patients who had previously sustained a pancreatic injury. METHOD A large institutional database was interrogated to identify patients who developed a delayed pancreatic complication among those with pancreatic injuries treated between January 1990 and December 2013. The degree of the pancreatic duct injury was graded using a new duct injury grading system and endoscopic therapeutic outcome assessed according to the grade of injury. RESULTS During the period under review, 432 consecutive patients were treated for pancreatic injuries of whom 27 (20 men, 7 women, median age 31, range 15-68 years) presented with delayed complications related to the initial pancreatic injury. Sixteen patients had non-resolving symptomatic pancreatic pseudocysts, 10 had persistent pancreatic fistulae and 1 had a symptomatic duct stricture. Fourteen patients with grade 2a, 3a, 3b or 4c main pancreatic duct injuries were successfully treated endoscopically with either pancreatic duct stenting or pseudocyst drainage while 13 patients with grade 4a or 4b duct injuries who had complete duct division with a disconnected duct syndrome failed endoscopic management and required surgical intervention. The 27 patients underwent a total of 49 endoscopic procedures (47 elective, 2 emergency) of whom 4 developed complications related to the endoscopic treatment. All 4 resolved, 2 after urgent endoscopic re-intervention. CONCLUSION In this preliminary analysis the Cape Town pancreatic ductal injury grading classification showed a close correlation with outcome after endoscopic and operative intervention.

An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries

INTRODUCTION Penetrating injuries of the pancreas may result in serious complications. This study assessed the factors influencing morbidity after stab wounds of the pancreas. METHODS A retrospective univariate cohort analysis was carried out of 78 patients (74 men) with a median age of 26 years (range: 16-62 years) with stab wounds of the pancreas between 1982 and 2011. RESULTS The median revised trauma score (RTS) was 7.8 (range: 2.0-7.8). Injuries involved the body (n=36), tail (n=24), head/uncinate process (n=16) and neck (n=2) of the pancreas. All 78 patients underwent a laparotomy. Sixty-five patients had AAST (American Association for the Surgery of Trauma) grade I or II pancreatic injuries and thirteen had grade III, IV or V injuries. Eight patients (10.3%) had an initial damage control operation. Sixty-nine patients (84.6%) had drainage of the pancreas only, six had a distal pancreatectomy and one had a pancreaticoduodenectomy. Most pancreas related complications occurred in patients with AAST grade III injuries; eight patients (10.2%) developed a pancreatic fistula. Four patients (5.1%) died. Grade of pancreatic injury (AAST grade I-II vs grade III-V injuries, p<0.001), RTS (odds ratio [OR]: 5.01, 95% confidence interval [CI]: 1.46-17.19, p<0.007), presence of shock on admission (OR: 3.31, 95% CI: 1.16-9.42, p=0.022), need for a blood transfusion (OR: 6.46, 95% CI: 2.40-17.40, p<0.001) and repeat laparotomy (p<0.001) had a significant influence on the development of general complications. CONCLUSIONS Although mortality was low after a pancreatic stab wound, morbidity was high. Increasing AAST grade of injury, high RTS, shock on admission to hospital, need for blood transfusion and repeat laparotomy were significant factors related to morbidity.

Outcome in decompensated alcoholic cirrhotic patients with acute variceal bleeding

BACKGROUND Variceal bleeding (VB) is the leading cause of death in cirrhotic patients with oesophageal varices. We evaluated the efficacy of emergency endoscopic intervention in controlling acute variceal bleeding and preventing rebleeding and death during the index hospital admission in a large cohort of consecutively treated alcoholic cirrhotic patients after a first variceal bleed. METHODS From January 1984 to August 2011, 448 alcoholic cirrhotic patients (349 men, 99 women; median age 50 years) with VB underwent endoscopic treatments (556 emergency, 249 elective) during the index hospital admission. Endoscopic control of initial bleeding, variceal rebleeding and survival after the first hospital admission were recorded. RESULTS Endoscopic intervention alone controlled VB in 394 patients (87.9%); 54 also required balloon tamponade. Within 24 hours 15 patients rebled; after 24 hours 61 (17%, n=76) rebled; and 93 (20.8%) died in hospital. No Child-Pugh (C-P) grade A patients died, while 16 grade B and 77 grade C patients died. Mortality increased exponentially as the C-P score increased, reaching 80% when the C-P score exceeded 13. CONCLUSION Despite initial control of variceal haemorrhage, 1 in 6 patients (17%) rebled during the first hospital admission. Survival (79.2%) was influenced by the severity of liver failure, with most deaths occurring in C-P grade C patients.

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.