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Objective: Acute Pancreatitis (AP) is sudden onset pancreas inflammation that causes systemic injury with a wide and markedly heterogeneous range of clinical consequences. Here, we hypothesised that this observed clinical diversity corresponds to diversity in molecular subtypes that can be identified in clinical and multi-omics data.Summary Background data: Observational cohort study. n=57 for the discovery cohort (clinical, transcriptomics, proteomics and metabolomics data) and n=312 for the validation cohort (clinical and metabolomics data).Methods: We integrated co-incident transcriptomics, proteomics, and metabolomics data at serial time points between admission to hospital and up to 48 hours after recruitment from a cohort of patients presenting with acute pancreatitis. We systematically evaluated four different metrics for patient similarity using unbiased mathematical, biological and clinical measures of internal and external validity. We next compared the AP molecular endotypes with previous descriptions of endotypes in a critically ill population with acute respiratory distress syndrome (ARDS).Results: Our results identify four distinct and stable AP molecular endotypes. We validated our findings in a second independent cohort of patients with AP.We observed that two endotypes in AP recapitulate disease endotypes previously reported in ARDS.Conclusions: Our results show that molecular endotypes exist in AP and reflect biological patterns that are also present in ARDS, suggesting that generalisable patterns exist in diverse presentations of critical illness.

Acute pancreatitis (AP) is sudden onset pancreas inflammation that causes multiple organ dysfunction syndrome (MODS) and death in certain individuals who develop AP yet minimal systemic inflammation in others. Here, we show that this observed diversity in systemic response and outcome is accompagnied by diversity in molecular subtypes that can be identified using computational analysis of clinical and multiomic data. We integrated co-incident whole blood transcriptomic, plasma proteomic, and serum metabolomic data at serial time points from a cohort of patients presenting with AP and systematically evaluated four different metrics for patient similarity, using unbiased mathematical, biological and clinical measures of internal and external validity. Our results identify four distinct and stable AP endotypes that are characterized by pathway and biomarker combination stereotypes into hypermetabolic, hepatopancreaticobiliary, catabolic and innate immune endotypes. The catabolic endotype in AP strikingly recapitulates a disease endotype previously reported in acute respiratory distress syndrome, a recognized complication of AP. Our findings demonstrate that clinically-relevant and generalizable endotypes exist in AP.

Introduction Severe acute pancreatitis (AP) requiring critical care admission (ccAP) impacts negatively on long-term survival. Objective To document organ-specific new morbidity and identify risk factors associated with premature mortality after an episode of ccAP. Design Cohort study. Setting Electronic healthcare registries in Scotland. Participants The ccAP cohort included 1471 patients admitted to critical care with AP between 1 January 2008 and 31 December 2010 followed up until 31 December 2014. The population cohort included 3450 individuals from the general population of Scotland frequency-matched for age, sex and social deprivation. Methods Record linkage of routinely collected electronic health data with population matching. Primary and secondary outcome measures Patient demographics, comorbidity (Charlson Comorbidity Index), acute physiology, organ support and other critical care data were linked to records of mortality (death certificate data) and new-onset morbidity. Kaplan-Meier and Cox regression analyses were used to identify risk factors associated with mortality. Results 310 patients with AP died during the index admission. Outcomes were not ascertained for five patients, and the deprivation quintile was not known for six patients. 340 of 1150 patients in the resulting postdischarge ccAP cohort died during the follow-up period. Greater comorbidity measured by the Charlson score, prior to ccAP, negatively influenced survival in the hospital and after discharge. The odds of developing new-onset diabetes mellitus after ccAP compared with the general population were 10.70 (95% CI 5.74 to 19.94). A new diagnosis of myocardial infarction, stroke, heart failure, liver disease, peptic ulcer, renal failure, cancer, peripheral vascular disease and lung disease was more frequent in the ccAP cohort than in the general population. Conclusions The persistent deleterious impact of severe AP on long-term outcome and survival is multifactorial in origin, influenced by pre-existing patient characteristics and acute episode features. Further mechanistic and epidemiological investigation is warranted.

To determine the impact of a 'Hot Clinic' (HC) on emergency general surgery patient flow-through.Prospective service evaluation study.HC is a four-bedded area coordinated by a specialist nurse. The HC consultant sees emergency patients referred from the emergency department, general practitioners or those in preceding 24 h considered suitable for interim discharge while awaiting investigations and HC reassessment.All patients with acute abdominal pain were evaluated in three 4 week groups: before (group 1), 1 month (group 2) and 6 months after the HC was introduced (group 3). Interhospital transfers, intrahospital ward referrals and trauma patients were excluded.Introduction of consultant-led surgical HC every weekday afternoon.Proportion of patients admitted under general surgeons, length of inpatient stay and the proportion of patients referred again within 3 months were investigated.1409 patients were referred, of which 1061 met the inclusion criteria: 307 in group 1, 326 in group 2 and 428 in group 3. There was no difference in gender distribution (p=0.759). Inpatient admissions were significantly reduced (85.0% vs 78.2% vs 54.4%; p0.001) and the inpatient duration of stay was significantly shorter after HC introduction (median (IQR) (95% CI) 63.8 (29.0-111.6) (51.8 to 72.8) hours vs 48.8 (21.7-101.2) (42.0 to 55.6) hours vs 47.7 (20.9-92.7) (42.8 to 56.9) hours; p=0.011).Emergency general surgery HCs are associated with significant reductions in admission rates and inpatient bed occupancy. This service redesign has the potential to dramatically relieve pressure on acute surgical services.

Transcription factor NF-E2 p45-related factor 2 (Nrf2, also called Nfe2l2), a master regulator of redox homeostasis, and its dominant negative regulator, Kelch-like ECH-associated protein 1 (Keap1), together tightly control the expression of numerous detoxifying and antioxidant genes. Nrf2 and the 'antioxidant response element' (ARE)-driven genes it controls are frequently upregulated in pancreatic cancer and correlate with poor survival. Upregulation of Nrf2 is, at least in part, K-Ras oncogene-driven and contributes to pancreatic cancer proliferation and chemoresistance. In this review, we aim to provide an overview of Keap1-Nrf2 signalling as it relates to pancreatic cancer, discussing the effects of inhibiting Nrf2 or Nrf2/ARE effector proteins to increase chemosensitivity.

Benign liver lesions are common and can pose a diagnostic challenge due to the difficulty in differentiating them from malignant hepatic lesions. They seldom present as an emergency. They are usually asymptomatic and are frequently detected incidentally during investigations for other conditions. Symptomatic lesions usually cause non-specific symptoms. Liver function tests are usually within the normal range, and diagnosis is established by abdominal ultrasound, computed tomography, magnetic resonance imaging or positron emission tomography. Further diagnostic modalities may include hepatic angiography and diagnostic laparoscopy with intraoperative ultrasonography. Biopsy or aspiration in the diagnosis of benign disease of the liver needs careful thought and multidisciplinary discussion and is contraindicated in certain scenarios due to the risk of bleeding and tumour seeding. Management strategies may vary from simple reassurance, lifestyle advice and observation through surveillance imaging, to complex hepatic resections or liver transplantation. Awareness of the natural history, clinical presentation and management strategies will ensure appropriate initial diagnostic work-up and prompt referral to a specialist hepatobiliary unit.

BackgroundThe effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.ObjectiveThe aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.MethodsA 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 Cox's proportional hazards methods.ResultsA 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

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.

Inhibition of kynurenine 3-monooxygenase (KMO) protects against multiple organ dysfunction (MODS) in experimental acute pancreatitis (AP). We aimed to precisely define the kynurenine pathway activation in relation to AP and AP-MODS in humans, by carrying out a prospective observational study of all persons presenting with a potential diagnosis of AP for 90 days. We sampled peripheral venous blood at 0, 3, 6, 12, 24, 48, 72 and 168 hours post-recruitment. We measured tryptophan metabolite concentrations and analysed these in the context of clinical data and disease severity indices, cytokine profiles and C-reactive protein (CRP) concentrations. 79 individuals were recruited (median age: 59.6 years; 47 males, 59.5%). 57 met the revised Atlanta definition of AP: 25 had mild, 23 moderate, and 9 severe AP. Plasma 3-hydroxykynurenine concentrations correlated with contemporaneous APACHE II scores (R2 = 0.273; Spearman rho = 0.581; P 2 = 0.132; Spearman rho = 0.455, P

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 ESystemic 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.

A best evidence topic was written according to a structured protocol. The question addressed was whether early laparoscopic cholecystectomy (ELC) in patients presenting with a short history of acute cholecystitis provides better post-operative outcomes than a delayed laparoscopic cholecystectomy (DLC). A total of 92 papers were found using the reported searches of which 10 represented the best evidence; 3 meta-analyses, 4 randomized control trials, 1 prospective controlled study and 2 retrospective cohort studies were included. The authors, date, journal, study type, population, main outcome measures and results were tabulated. No significant difference in complication or conversion rates were shown between the ELC and the DLC group, in the meta-analyses of Gurusamy et al, Lau et al and Siddiqui et al. The ELC group had a decreased hospital stay whereas the DLC group presented a considerable risk for subsequent emergency surgery during the interval period, with a high rate of conversion to open cholecystectomy. All three meta-analyses were based on the randomized control trials of Lo et al, Lai et al, Kolla et al and Johansson et al; the results of each study are summarized. We conclude that there is strong evidence that early laparoscopic cholecystectomy for acute cholecystitis offers an advantage in the length of hospital stay without increasing the morbidity or mortality. The operating time in ELC can be longer, however the incidence of serious complications (i.e. common bile duct injury), is comparable to the DLC group. Larger randomized studies are required before solid conclusions are reached.

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.

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.

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.

The value of lung ultrasonography in the diagnosis of respiratory dysfunction and severity stratification in patients with acute pancreatitis (AP) was investigated.Over a 3-month period, 41 patients (median age: 59.1 years; 21 males) presenting with a diagnosis of potential AP were prospectively recruited. Each participant underwent lung ultrasonography, and the number of comet tails present on scans was linked with contemporaneous clinical data. Group comparisons, areas under the curve (AUC) and respective measures of diagnostic accuracy were investigated.A greater number of comet tails were evident in patients with respiratory dysfunction (P = 0.013), those with severe disease (P = 0.001) and when contemporaneous and maximum in-patient C-reactive protein (CRP) exceeded 150 mg/l (P = 0.018 and P = 0.049, respectively). Receiver-operator characteristic plot area under the curve (AUC) was greater when examining upper lung quadrants, using respiratory dysfunction and AP severity as variables of interest (AUC = 0.803, 95% CI: 0.583-1.000, and AUC = 0.996, 95% CI: 0.983-1.000, respectively). Examining all lung quadrants resulted in greater AUCs for contemporaneous and maximum CRP (AUC = 0.764, 95% CI: 0.555-0.972, and AUC = 0.704, 95% CI: 0.510-0.898).Ultrasonography of non-dependent lung parenchyma can reliably detect evolving respiratory dysfunction in AP. This simple bedside technique shows promise as an adjunct to severity stratification.

Pancreatic cancer is one of the most lethal cancers, and continues to be a major health problem in the twenty-first century. Early-stage disease is usually clinically silent, or manifests with non-specific symptoms that often go unrecognised; therefore, diagnosis is invariably dependent on imaging methods. Although transabdominal ultrasound imaging (TAUS) is frequently the first-line diagnostic approach for patients presenting with jaundice and/or upper abdominal pain, computerized tomography (CT) is the most commonly used imaging method for the diagnosis and staging of pancreatic cancer. The more sensitive multiphase, multidetector helical CT constitutes the method of choice. In addition, magnetic resonance imaging (MRI) can also detect primary pancreatic tumours as well as regional and distant metastases, and, in recent years, positron emission tomography (PET) – stand-alone or in combination with CT – has been established as a useful adjunct. Recently, endoscopic ultrasonography (EUS) has gained popularity as a promising staging modality, and it currently has a complementary role to CT for the evaluation of patients with pancreatic cancer. Nevertheless, despite recent technologic advancements in the diagnostic approach to pancreatic cancer and the refinement of the clinical staging algorithm, early diagnosis remains challenging and a substantial improvement in patient outcomes has not yet been observed.

Introduction: Perforated gastric ulcers are potentially complicated surgical emergencies and appropriate early management is essential in order to avoid subsequent problems including unnecessary gastrectomy. The aim of this study was to examine the management and outcome of patients with gastric ulcer perforation undergoing emergency laparotomy for peritonitis. Methods: Patients undergoing laparotomy at the Royal Infirmary of Edinburgh for perforated gastric ulcers were identified from the prospectively maintained Lothian Surgical Audit (LSA) database over the five-year period 2007e2011. Additional data were obtained by review of electronic records and review of case notes. Results: Forty-four patients (25 male,19 female) were identified. Procedures performed were: 41 omental patch repairs (91%), 2 simple closures (4.5%) and 2 distal gastrectomies (4.5%; both for large perforations). Four perforated gastric tumours were identified (8.8%), 2 of which were suspected intra-operatively and confirmed histologically, 1 had unexpected positive histology and 1 had negative intra-operative histology, but follow-up endoscopy confirmed the presence of carcinoma (1 positive biopsy in 21 follow-up endoscopies); all 4 were managed without initial resection. Median length of stay was 10 days (range 4e68). Overall 7 patients died in hospital (15.9%) and there were 21 morbidities (54.5%). Registrars performed the majority of the procedures (16 alone, 21 supervised) with no significant difference in postoperative morbidity (P ¼ 0.098) or mortality (P ¼ 0.855), compared to consultants. Conclusion: Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Initial biopsy and follow-up endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy.

Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. Adult patients undergoing elective and emergency general, orthopaedic, gynaecology and vascular surgery procedures in the Royal Infirmary of Edinburgh were surveyed over a 3-month period commencing November 2011. A standardised questionnaire was used to collect information on the duration of preoperative fasting and the advice administered by medical and nursing staff. 292 patients were included. Median fast from solids was 13.5 h for elective patients (IQR 11.5–16) and 17.38 h for emergency patients (IQR 13.68–28.5 h). Similarly, the median fast from fluids was 9.36 h for elective patients (IQR 5.38–12.75 h) and 12.97 h for emergency patients (IQR 8.5–16.22 h). The instructions that elective patients received contributed to prolonged fasting times. The median fast for elective patients fully compliant with fasting advice would be 10 h for solids (IQR 8.75–12 h) and 6.25 h (IQR 3.83–9.25 h) for clear fluids. Elective patients fasted for longer than recommended confirming that clinical practice is slow to change. The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.

This study was commissioned by GSK through the Farr Institute/SHIP/eDRIS single portal. DJM is a Clinician Scientist Fellow funded by the Health Foundation/Academy of Medical Sciences. 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. Publisher PDF

A best evidence topic was written according to a structured protocol. The question addressed was whether early laparoscopic cholecystectomy (ELC) in patients presenting with a short history of acute cholecystitis provides better post-operative outcomes than a delayed laparoscopic cholecystectomy (DLC). A total of 92 papers were found using the reported searches of which 10 represented the best evidence; 3 meta-analyses, 4 randomized control trials, 1 prospective controlled study and 2 retrospective cohort studies were included. The authors, date, journal, study type, population, main outcome measures and results were tabulated. No significant difference in complication or conversion rates were shown between the ELC and the DLC group, in the meta-analyses of Gurusamy et al, Lau et al and Siddiqui et al. The ELC group had a decreased hospital stay whereas the DLC group presented a considerable risk for subsequent emergency surgery during the interval period, with a high rate of conversion to open cholecystectomy. All three meta-analyses were based on the randomized control trials of Lo et al, Lai et al, Kolla et al and Johansson et al; the results of each study are summarized. We conclude that there is strong evidence that early laparoscopic cholecystectomy for acute cholecystitis offers an advantage in the length of hospital stay without increasing the morbidity or mortality. The operating time in ELC can be longer, however the incidence of serious complications (i.e. common bile duct injury), is comparable to the DLC group. Larger randomized studies are required before solid conclusions are reached.

Pancreatitis associated with the extension of a pancreatic collection, pseudocyst or abscess into the groin is a rare phenomenon with few reports in the English literature. Nevertheless, it remains a clinically important differential diagnosis as it may be mistaken for more common pathologies in the groin and with a subsequent unnecessary surgical intervention. A case of this rare complication of pancreatitis is reported, together with a review of the literature.

IntroductionIdiopathic 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 caseWe 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.DiscussionThe 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.ConclusionA 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.

Background: The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients. Methods: Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients' parameters in our database. Results: Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero. Conclusions: LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.

Introduction Lung ultrasonography has been proposed as a useful method for diagnosing alveolar-interstitial syndrome, based on the detection and quantification of comet-tail artefacts. The aim of the present study was to investigate its value in the diagnosis of respiratory dysfunction and severity stratification in patients with acute pancreatitis (AP). Method This prospective pilot study received ethical committee approval, and written informed consent was obtained from all participants or their surrogates. Between September and December 2013, 41 patients (median age: 59.1 years; 21 males) presenting to the Royal Infirmary of Edinburgh with a potential diagnosis of AP were recruited. Each participant underwent lung ultrasonography and the number of comet-tail artefacts was linked with contemporaneous, prospectively collected clinical data. Patient group comparisons, areas under the curve (AUC) and respective measures of diagnostic accuracy were examined in relation to: i. Respiratory dysfunction status, ii. Disease severity, as defined by the revised Atlanta criteria for AP, iii. C-Reactive Protein contemporaneous with the scan, and iv. Maximum CRP value of the first week of admission. The results were analysed for all lung quadrants, all quadrants except for the lower lateral, and upper quadrants alone. Results A greater number of comet tails were evident in patients with respiratory dysfunction, those with severe disease and when contemporaneous and maximum CRP were above 100 mg/L (P = 0.021; P Conclusion Ultrasonography of non-dependant lung parenchyma can reliably detect evolving respiratory dysfunction in acute pancreatitis and is potentially useful for severity stratification. This simple, easily repeatable bedside test deserves further validation in a larger cohort. Disclosure of interest None Declared.

Introduction Perforated gastric ulcers are potentially complicated surgical emergencies. Appropriate early management is essential to avoid subsequent problems including the detection of underlying malignancy. Our aim was to examine the management and outcome of patients with gastric perforations undergoing emergency laparotomy for peritonitis. Methods Patients undergoing laparotomy in the department of General Surgery for perforated gastric ulcers were identified from the prospectively maintained Lothian Surgical Audit (LSA) database over the 5-year period 2007–2011. Additional data were obtained by review of electronic records and the endoscopy reporting system (UNISOFT), in addition to reference with the South East Scotland oesophagogastric Cancer Network (SCAN) database and the histopathology laboratory Database (APEX). Results 45 patients were identified. The procedures performed were: 41 omental patch repairs (91%), two simple closures (4%) and two distal gastrectomies (4%—both for large perforations). There were four perforated gastric tumours (4%), of which two were suspected intra-operatively and confirmed histologically, one had unexpected positive histology and one had negative histology, but follow-up endoscopy confirmed carcinoma; all four were managed without resection at initial laparotomy. One of these patients underwent subsequent resection for cancer after full staging and optimisation but subsequently developed tumour recurrence and died. Median length of stay was 8 days (range 4–68). The overall inpatient mortality was 15% and there were 20 morbidities (44%; including nine respiratory complications, four wound infections and two myocardial infarctions). 33 patients had biopsies taken during surgery. Two of the remaining 12 patients had biopsies taken during postoperative endoscopy. None of the remaining 10 patients were subsequently referred with cancer. Seventeen patients in total underwent a follow-up postoperative endoscopy and 11 of them had biopsies taken. Conclusion The majority of perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Initial biopsy and follow-up endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy. Competing interests None declared.

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.

Background A 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. Methods The 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. Results The 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. Conclusion The 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.