Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team

Pancreatic surgery units undertake several complex operations,albeit with consi-derable morbidity and mortality,as is the case for the management of complicated acute pancreatitis or chronic pancreatitis.The centralisation of pancreatic surgery services,with the development of designated large-volume centres,has contribu-ted to significantly improved outcomes.In this editorial,we discuss the complex associations between diabetes mellitus(DM)and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis,highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services.Type 3c pan-creatogenic DM,refers to DM developing in the setting of exocrine pancreatic disease,and its identification and management can be challenging,while the glycaemic control of such patients may affect their course of treatment and outcome.Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period.The incidence of new onset diabetes after pancreatic resection is widely variable in the literature,and depends on the type and extent of pancreatic resection,as is the case with pancreatic parenchymal loss in the context of severe pancreatitis.Early involvement of a specialist diabetes team is essential to ensure a holistic management.In the current era,large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery,with inclusion of provisions for optimisation of the perioperative glycaemic control,to improve outcomes.While various guidelines are available to aid perioperative management of DM,auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement.The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined,a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis.Therefore,pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams.With the ongoing accumulation of evidence,it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.

Current and future role of three-dimensional modelling technology in rectal cancer surgery:A systematic review

BACKGROUND Three-dimensional(3D)modelling technology translates the patient-specific anatomical information derived from two-dimensional radiological images into virtual or physical 3D models,which more closely resemble the complex environment encountered during surgery.It has been successfully applied to surgical planning and navigation,as well as surgical training and patient education in several surgical specialties,but its uptake lags behind in colorectal surgery.Rectal cancer surgery poses specific challenges due to the complex anatomy of the pelvis,which is difficult to comprehend and visualise.AIM To review the current and emerging applications of the 3D models,both virtual and physical,in rectal cancer surgery。METHODS Medline/PubMed,Embase and Scopus databases were searched using the keywords“rectal surgery”,“colorectal surgery”,“three-dimensional”,“3D”,“modelling”,“3D printing”,“surgical planning”,“surgical navigation”,“surgical education”,“patient education”to identify the eligible full-text studies published in English between 2001 and 2020.Reference list from each article was manually reviewed to identify additional relevant papers.The conference abstracts,animal and cadaveric studies and studies describing 3D pelvimetry or radiotherapy planning were excluded.Data were extracted from the retrieved manuscripts and summarised in a descriptive way.The manuscript was prepared and revised in accordance with PRISMA 2009 checklist.RESULTS Sixteen studies,including 9 feasibility studies,were included in the systematic review.The studies were classified into four categories:feasibility of the use of 3D modelling technology in rectal cancer surgery,preoperative planning and intraoperative navigation,surgical education and surgical device design.Thirteen studies used virtual models,one 3D printed model and 2 both types of models.The construction of virtual and physical models depicting the normal pelvic anatomy and rectal cancer,was shown to be feasible.Within the clinical context,3D models were used to identify vascular anomalies,for surgical planning and navigation in lateral pelvic wall lymph node dissection and in management of recurrent rectal cancer.Both physical and virtual 3D models were found to be valuable in surgical education,with a preference for 3D printed models.The main limitations of the current technology identified in the studies were related to the restrictions of the segmentation process and the lack of 3D printing materials that could mimic the soft and deformable tissues.CONCLUSION 3D modelling technology has potential to be utilised in multiple aspects of rectal cancer surgery,however,it is still at the experimental stage of application in this setting.

Near-fatal Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia,shock and complicated extracorporeal membrane oxygenation cannulation:A case report

BACKGROUND Panton-Valentine leukocidin(PVL)is an exotoxin secreted by Staphylococcus aureus(S.aureus),responsible for skin and soft tissue infections.As a cause of severe necrotising pneumonia,it is associated with a high mortality rate.A rare entity,the epidemiology of PVL S.aureus(PVL-SA)pneumonia as a complication of influenza coinfection,particularly in young adults,is incompletely understood.CASE SUMMARY An adolescent girl presented with haemoptysis and respiratory distress,deteriorated rapidly,with acute respiratory distress syndrome(ARDS)and profound shock requiring extensive,prolonged resuscitation,emergency critical care and venovenous extracorporeal membrane oxygenation(ECMO).Cardiac arrest and a rare complication of ECMO cannulation necessitated intra-procedure extracorporeal cardiopulmonary resuscitation,i.e.,venoarterial ECMO.Coordinated infectious disease,microbiology and Public Health England engagement identified causative agents as PVL-SA and influenza A/H3N2 from bronchial aspirates within hours.Despite further complications of critical illness,the patient made an excellent recovery with normal cognitive function.The coordinated approach of numerous multidisciplinary specialists,nursing staff,infection control,specialist cardiorespiratory support,hospital services,both adult and paediatric and Public Health are testimony to what can be achieved to save life against expectation,against the odds.The case serves as a reminder of the deadly nature of PVL-SA when associated with influenza and describes a rare complication of ECMO cannulation.CONCLUSION PVL-SA can cause severe ARDS and profound shock,with influenza infection.A timely coordinated multispecialty approach can be lifesaving.

Surgical chylothorax in neonates:management and outcomes

Background Postoperative chylothorax occurs due to trauma to lymphatic vessels and can occur after any thoracic proce-dure.This study reviewed recent literature to evaluate the management and outcomes of surgical chylothorax in neonates.Methods PubMed database was searched for articles in English,Portuguese and Spanish from 2000 to 2016.Data were collected for surgery,chylothorax management,complications,mortality and length of hospital stay(LOS).Results Twenty studies offered 107 neonates:congenital diaphragmatic hernia(CDH)(n=76,71%),cardiac malforma-tions(n=25,23.4%),esophageal atresia(n=5,4.7%)and CDH+extralobar sequestration(n=1,0.9%).Medium-chain tri-glycerides(MCT)was the initial treatment in 52 neonates(48.6%),prednisolone+MCT in one(0.9%),total parenteral nutri-tion in 51 patients(47.7%),and three patients(2.8%)did not require any treatment.Octreotide and somatostatin were used as second or third line treatment in 25 neonates(23.4%),and 15 neonates(14%)underwent 17 surgeries,including thoracic duct ligation(TDL)(n=9);pleurodesis(n=3)(2 patients required TDL);TDL+pleurodesis(n=2),and TDL+placement of hemostat(n=1).Complications due to the chylothorax were reported in 27 neonates(25.2%):hypoalbuminemia+hypona-tremia(n=18),hypoalbuminemia(n=4),hypoalbuminemia with cutaneous flushing as colateral effect of somatostatin(n=1),loose stool after somatostatin use(n=1),pneumonia(n=1),congestive heart failure+hypernatremia(n=1),and hyponatremia(n=1).There were 21 deaths(19.6%)and median LOS was 53.4 days(30-93.1 days).Conclusions Conservative management is appropriate as initial treatment for neonatal postsurgical chylothorax.Octreotide and somatostatin are safe in neonates and surgical approach should be considered in prolonged leaks.

如何与失聪或有听力障碍的患者交流

在英国,每7人中约有1人有听力损失,70岁以上的人中听力损失者高达一半人口1。世界卫生组织的数据显示,2018年有4.66亿人(占世界人口的6.1%)有听力损失;预计到2030年这一数字将上升到6.3亿2。失聪(D/deaf,详见框图1术语说明)患者的表征各不相同,包括从在嘈杂环境中理解言语的轻度困难,到很少或不能理解言语。在英格兰和威尔士,估计有90万人是重度或极重度失聪,其中约7万人将英国手语(BSL)作为他们的第一语言3。世界失聪人群联合会(The World Federation for the Deaf)估计,全球有7200万失聪者(deaf)使用300多种不同的手语,其中80%以上的人生活在发展中国家4。