HIDA scan for functional gallbladder disorder： ensure that you know how the scan was done

BACKGROUND： Despite the increasing use of fatty meal（FM） as a substitute for cholecystokinin（CCK） in pain reproduction during hepato-imino-diacetic acid（HIDA） scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application. METHODS： Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups： those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results.RESULTS： Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction（61% vs 30%, P〈0.01）.CONCLUSIONS： Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.

Differentiating intraductal papillary mucinous neoplasms from other pancreatic cystic lesions

Intraductal papillary mucinous neoplasms(IPMN) can be difficult to distinguish from other cystic lesions of the pancreas.To understand better and discuss the current knowledge on this topic,the literature and the institutional experience at a large pancreatic disease center have been reviewed.A combination of preoperative demographic,historical,radiographic,laboratory data,as well as postoperative pathologic analyses can often distinguish IPMN from other lesions in the differential diagnosis.

Pancreatic duct disruption and nonoperative management: the SEALANTS approach

Pancreatic-duct disruption (PDD) can be difficult to manage, with diverse etiologies and sequelae in a heterogeneous population. Common etiologies include pancreatitis, iatrogenic injury, and trauma. Sequelae of PDD include pseudocyst, pancreatic ascites,

Minimally invasive and open gallbladder cancer resections: 30-vs 90-day mortality

BACKGROUND:Minimally invasive surgery is increasingly used for gallbladder cancer resection.Postoperative mortality at 30 days is low,but 90-day mortality is underreported.METHODS:Using National Cancer Database(1998-2012),all resection patients were included.Thirty-and 90-day mortality rates were compared.RESULTS:A total of 36 067 patients were identified,19 139(53%) of whom underwent resection.Median age was 71 years and 70.7% were female.Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality(17.1% vs 7.4%).There was a statistically significant increase in 30-and 90-day mortality with poorly differentiated tumors,presence of lymphovascular invasion,tumor stage,incomplete surgical resection and low-volume centers(P<0.001 for all).Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012,the 90-day mortality was 2.8-fold higher than the 30-day mortality(12.0% vs 4.3%).CONCLUSIONS:Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality.Postoperative mortality is associated with tumor grade,lymphovascular invasion,tumor stage,type and completeness of surgical resection as well as type and volume of facility.

The “Colonial Wig” pancreaticojejunostomy:zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

BACKGROUND: Postoperative pancreatic fistula(POPF) remains common and morbid after pancreaticoduodenectomy(PD). A major advance in the study of POPF is the fistula risk score(FRS).METHODS: We analyzed 48 consecutive patients undergoing PD. The 'Colonial Wig' pancreaticojejunostomy(CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. RESULTS: Postoperative morbidity was 49%(27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF(CR-POPF) rate was 15%, similar to the FRS-predicted rate(14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups(14% vs 13%), the CRPOPF rate in the CWPJ group was 0(P=0.052).CONCLUSION: Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

Trends and seasonality in hospitalizations for acute alcohol-related and biliary pancreatitis in the USA

Background:The incidence of acute pancreatitis(AP)is characterized by circannual and geographical variation.The aim of this study was to describe seasonal variation and trends in hospitalizations for AP in the USA with respect to AP etiology.Methods:The Nationwide Inpatient Sample data(2000–2016)from the Healthcare Cost and Utilization Project were used.The study population included all primary hospitalizations for AP.Biliary AP(BAP)and alcohol-induced AP(AAP)were distinguished by diagnostic and procedural ICD codes.Seasonal trend decomposition was performed.Results:There was a linear increase in annual incidence(per 100000 population)of AAP in the USA(from 17.0 in 2000 to 22.9 in 2016),while incidence of BAP,equaled 19.9 in 2000,peaked at 22.1 in 2006 and decreased to 17.4 in 2016.AP incidence demonstrated 18%annual incidence amplitude with summer peak and winter trough,more prominent in AAP.In 2016,within AAP,the highest incidence(per 100000 population)was noted among African-Americans(up to 50.4),followed by males aged 56–70 years(26.5)and Asians of low income(25.5);within BAP,above the average incidence was observed in Hispanic(up to 25.8)and Asian(up to 25.0)population.The most consistent and rapid increase in AP incidence was noted in males aged 56–70 years with an alcoholic etiology(average 6%annual incidence growth).Conclusions:The incidence and annual trends of AP vary significantly among demographic and socioeconomic groups and this knowledge may be useful for the planning of healthcare resources and identification of at-risk populations.

Intrahepatic pancreatic pseudocyst:A review of the world literature

AIM To investigate and summarize the literature regarding the diagnosis and management of intrahepatic pancreatic pseudocysts(IHPP).METHODS A literature search was performed using Pub Med(MEDLINE) and Google Scholar databases, followed by a manual review of reference lists to ensure that no articles were missed. All articles, case reports, systematic reviews, letters to editors, and abstracts were analyzed and tabulated. Bivariate analyses were performed, with significance accepted at P < 0.05. Articles included were primarily in the English language, and articles in other languages were reviewed with native speakers or, if none available, were translated with electronic software when possible. RESULTS We found 41 published articles describing 54 cases since the 1970 s, with a fairly steady rate of publication. Patients were predominantly male, with a mean age of 49 years. In 42% of published cases, the IHPP was the only reported pseudocyst, but 58% also had concurrent pseudocysts in other extrapancreatic locations. Average IHPP size was 9.5 cm and they occurred most commonly(48%) in the left hemiliver. Nearly every reported case was managed with an intervention, most with a single intervention, but some required up to three interventions. Percutaneous treatment with either simple aspiration or with an indwelling drain were the most common interventions, frequently performed along with stenting of the pancreatic duct. The size of the IHPP correlated significantly with both the duration of treatment(P = 0.006) and with the number of interventions required(P = 0.031). The duration of therapy also correlated with the initial white blood cell(WBC) count(P = 0.048).CONCLUSION Diagnosis of IHPP is difficult and often missed. Initial size and WBC are predictive of the treatment required. With appropriate intervention, most patients achieve resolution.

Detecting accidental punctures and lacerations during cholecystectomy in large datasets: Two methods of analysis

Background: After the Institute of Medicine(IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality(AHRQ) developed Patient-Safety Indicators(PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations(APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. Methods: We used Nationwide Inpatient Sample(NIS) data(20 0 0–2012) from AHRQ’s Healthcare Cost and Utilization Project(H-CUP). We analyzed PSI-15-positive and-negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker(CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. Results: CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. Conclusions: Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.

Energetic etiologies of acute pancreatitis: A report of five cases

There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. However, cases of pancreatitis still occur in the absence of any recognizable factors, and these cases of idiopathic pancreatitis suggest the presence of unrecognized etiologies. Five cases of acute pancreatitis in four patients came to attention due to a strong temporal association with exposure to nerve stimulators and energy drinks. Given that these cases of pancreatitis were otherwise unexplained, and given that these exposures were not clearly known to be associated with pancreatitis, we performed a search for precedent cases and for mechanistic bases. No clear precedent cases were found in Pub Med and only scant, weak precedent cases were found in public-health databases. However, there was a coherent body of intriguing literature in support of a mechanistic basis for these exposures playing a role in the etiology of pancreatitis.

Subspecialty radiology and surgery

The Master said: "Yu! Shall I teach you the meaning of knowledge?When you know a thing to recognize that you know it; and when you do not, to know that you do not know