Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Safety and Anti-Fatigue Activity of Ayurvedic Formulation <i>Sramahara Mahaakaasaya</i> - A Pre-Clinical Study

An experimental evaluation of anti-fatigue activity of Shramahara Mahaakashaaya (SM) and its applicability in sports medicine has been systematically evaluated. Aqueous, ethanolic and petroleum ether extracts of SM granules (200mg/kg) were studies for light-dark model test for assessment anti-anxiety effect, rota-rod test for assessment of the effect on muscle tone and muscle balance, weight loaded forced swimming test for assessment of anti-fatigue activity. The acute toxicity study of SM granules has also been evaluated as per the OECD 423. SM granules showed significant anti-fatigue activity in different experimental models and found safe up to 2000mg/kg body weight dose. The results provide an important basis for considering Shramahara Mahaakashaaya (SM) as an alternative medicine having anti-fatigue effects which can be further included in the sports medicine.

Liver transplantation and COVID-19 (Coronavirus) infection: guidelines of the liver transplant Society of India (LTSI)

The Liver Transplant Society of India (LTSI) has come up with guidelines for transplant centres across the country to deal with liver transplantation during this evolving pandemic of COVID-19 infection. The guidelines are applicable to both deceased donor as well as living donor liver transplants. In view of the rapidly changing situation of COVID-19 infection in India and worldwide, these guidelines will need to be updated according to the emerging data.

The Radiologist and the Surgeon: The Journey from a Support Staff to the Most Valuable Player of the Clinical Team

Advancement in understanding of disease and availability of state-of-the-art tools for diagnosis and management have brought the radiologist and the surgeon closer. Close cooperation between them starting from initial presentation to postoperative follow-up spanning diagnosis, staging, treatment planning, interventions to management of disease sequelae, and complications has become the norm. This has benefited both clinicians and patients alike. Although better tools help in increasing accuracy, accuracy by itself does not imply precision. Technology cannot be a substitute for good clinical acumen or interaction between the surgeon and the radiologist. It is desirable that radiologists working in tertiary referral centers focus on two or three system-based specialties, so that they can keep pace with the latest developments in the field and deliver quality care. The new-age radiologist and surgeon should adapt to this changing scenario and increasing expectations. In the pursuit of clinical excellence, the radiologist has become the most valuable player in the clinical team.

Combating hospital malnutrition: Dietitian-led quality improvement initiative

BACKGROUND & AIM

Malnutrition is serious but under-diagnosed problem among hospitalized patients as approximately one-third patients may become malnourished during their stay. We audited our clinical nutrition practice (CNP) to understand the gaps and planned quality improvement initiatives to strengthen CNP through early delivery of oral nutrition supplement (ONS) prescribed.

METHOD

A prospective study was conducted in a tertiary care hospital in three phases between Dec'15 and Feb'17. Phase-1(P1): To assess the prevalence of malnutrition on admission and CNP; Phase-2(P2): Sensitization of Clinical Dietitians' to improve the nutrition care process; Phase-3(P3): Coalition of Multidisciplinary Team (MDT) to improve the timely delivery of ONS. Patients' demographics, baseline nutritional status (Subjective Global Assessment (SGA)), details of nutrition intervention and outcomes were recorded. Data were analyzed using SPSS version 20.0.

RESULTS

Out of 1443 patients (P1-500; P2-428; P3-515) enrolled, 63% were men and 37% women with mean age of 53.6 ± 15.49y. A significant improvement in the nutritional diagnosis as per SGA (0.031) and increasing trend in ONS prescription (P1:10(2%); P2:56(13%); P3:83(16%) (p = 0.000) was evident, which was attributed to the sensitization of Dietitians. Early delivery of ONS within 6 h from the time of prescription (EDONS) was progressively higher in P3 (P1:10%; P2:16.1%; P3:44.6%) and notable reversal of delayed delivery (>24 h) (P1:40%, P2:16%, P3:8.4%) (p = 0.000). Remarkable decline in the Length of Stay (LOS) was shown between the phases (P1:6.82 ± 10.3d; P2:5.68 ± 4.07d; P3:5.60 ± 4.74d) (p = 0.010). Vegetarians (6.54d) had a longer stay compared with non-vegetarians (5.88d) (p = 0.036). Lower BMI correlated negatively with LOS (p = 0.026). Univariant analysis showed a significant increase in LOS with admission history on weight loss (No weight loss = 5.52d, <10% loss = 7.74d, 10-15% = 7.51d, >15% = 8.32 d) (p = 0.001), severe malnutrition (12.67d) and EDONS in shortening the LOS (<6 h = 6.11, 6-12 h = 7.97, 12-24 h = 6.83, >24 h = 17.3 days) (p = 0.000). Multiple Linear regression analysis using ANOVA indicated that EDONS was the only major contributing factor in lowering the LOS (p = 0.002). Re-admission was higher in non ONS group (72%: non ONS; 26%: ONS group) (p = 0.000).

CONCLUSION

Dietitian-Led multi-professional inter-disciplinary Coalition, bridging the knowledge gap among MDT with regular sensitization about the importance of hospital malnutrition and EDONS, has led to the early identification and intervention of nutrition risk which enhanced progressive decrease in LOS and healthcare cost.

Customized nutrition intervention and personalized counseling helps achieve nutrition targets in perioperative liver transplant patients

BACKGROUND AND AIM

Nutritional therapy is an integral part of care in all phases of liver transplantation (LTx). However, there are several factors that make it a challenge to manage malnutrition in these patients including, but not limited to, loss of appetite, dietary restrictions and dietary habits. Dietary habits are guided by personal choice, social, cultural and regional background with diversity ranging from veganism to vegetarianism with the latter predominant in Indian population. Therefore, it is difficult to improve nutritional intake of patients with standard dietary recommendations. We evaluated the effects of implementing personalized dietary counseling and a customized nutrition plan on its ability to enhance oral intake and, thereby improve nutritional status of patients with end stage liver disease (ESLD) being evaluated for LTx. We compared the outcomes with a matched group of patients who were prescribed standard dietary recommendations from a historic database. Primary outcome was measured by number of patients achieving ≥75% of recommended energy and protein requirements during hospitalization for LTx. Secondary outcomes included mean energy and protein intake, hours of ventilation, length of stay in Intensive Care Unit (ICU) and hospital, mortality and readmission rate in the acute phase (3months) after LTx.

METHODS

This was a prospective observational study, performed at a single LTx centre. All patients >18years who enrolled for LTx and consented for the study were included. The study was conducted after obtaining institutional ethics committee approval. A protocol based nutrition planning was implemented from April'14. According to this protocol, all patients being evaluated for LTx underwent a detailed nutritional assessment by a qualified Clinical Dietitian (CD) and regularly followed up with until LTx. Nutritional intervention, including a customized nutrition care plan and personalized dietary counseling, was provided based on the severity of malnutrition. To evaluate the efficacy of this protocol, we compared the nutritional adequacy (calorie and protein intake) of 65 consecutive patients who underwent LTx between August'14-October'15 (group 1) with a historic database of 65 patients who underwent LTx between January'13 and April'14 (group 2). Patients' demographics, disease severity score, baseline markers of nutritional status (subjective global assessment (SGA), and body mass index (BMI)), were recorded. First, assessment of individual patient's oral energy and protein intake was determined by the daily calorie count during hospitalization. Then the nutritional intervention (oral nutrition supplement (ONS)/enteral nutrition (EN)/parenteral nutrition (PN)) plan was customized according to their spontaneous oral intake. As part of the protocol, health related quality of life was also assessed using short form 8 (SF-8) in group 1. Statistical analyses using Pearson's correlation, Chi-Square test were applied with SPSS version 20.0.

RESULTS

The mean age of group 1 and 2 were 52.6 ± 9.8, 51.9 ± 10.5 (range 25-70years) with BMI of 26.8 ± 6.0, 26.5 ± 5.4 respectively. According to SGA, there was significant improvement in the nutritional status of group 1 patients compared to group 2 on admission for LTx. It was indicated that 88% of group 1 individuals in comparison to 98% in group 2 were malnourished. The calorie intake of group 1 (1740.2 ± 254.8) was significantly higher than group 2 (1568.5 ± 321.6) (p = 0.005). The marked improvement in protein intake in group 1 (63.1 ± 12.1) when compared with group 2 (53.1 ± 13.4) was statistically significant (p = 0.008). A subset analysis showed that non-vegetarians (consuming meat and dairy products) between the groups showed that group 1 had a significantly higher calorie (p = 0.004) and protein (p = 0.0001) intake compared to individuals in group 2. Following implementation of study's protocol, the goal of achieving ≥75% of the prescribed calories (p = 0.013) and protein (p = 0.0001) was significantly higher in group 1.

CONCLUSION

When compared to the standard prescription, an individualized protocol to diagnose, stratify the severity of malnutrition early, and follow up by customized nutrition planning for patients helped to achieve nutritional targets more effectively. Inspite of patients' diversity in nutritional habits and reluctance to accept change, it is clear that a qualified and dedicated transplant nutrition team can successfully implement perioperative nutrition protocol to achieve better nutritional targets.

Enterococcal meningitis in association with Strongyloides hyperinfection syndrome

INTRODUCTION

Strongyloidiasis can cause hyperinfection or disseminated infection in an immunocompromised host, and is an important factor linked to enterococcal bacteremia and meningitis.

CASE REPORTS

We report two cases highlighting the importance of suspecting Strongyloides hyperinfection syndrome in patients with enterococcal meningitis.

CONCLUSION

Our cases highlight the importance of suspecting Strongyloides hyperinfection syndrome in cases of community acquired enterococcal bacteremia and meningitis.

Supra Hepatic Inferior Vena Cava Thrombosis-Surgical Challenges

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a chronic affliction characterized by numerous liver and kidney cysts. There is a gradual but progressive renal and liver impairment which may require combined liver-kidney transplantation. Compression of the retrohepatic Inferior Vena Cava (IVC) by an enlarged polycystic liver may impede clear visualization on pre-operative imaging and miss an underlying thrombosis or obliteration. This may result in an intra-operative surprise. Management can be challenging requiring modification of conventional surgical approach. We present our experience of a 67-year-old patient who underwent combined liver-kidney deceased donor transplantation for decompensated chronic liver disease with chronic kidney disease due to ADPKD. She was diagnosed with ADPKD for 16 year, with progressive deterioration in kidney function over the last 6 year and liver decompensation following knee replacement surgery requiring regular renal replacement therapy. We report this case to highlight the peri-operative challenges and their management along with a review of published literature on this uncommon occurrence.

Incidental Ventricular Septal Defect (VSD) in the Donor of a Live Donor Liver Transplant: Tackle and Proceed

Live Donor Liver Transplantation (LDLT) is an act of selflessness on the part of the donor who is subjected to a major hepatectomy. Ensuring safety and long-term well being of the donor is of utmost priority. We describe a 21-year-old otherwise healthy donor with perimembranous Ventricular Septal Defect (VSD) who successfully underwent donor hepatectomy after closure of the VSD. There is no literature available to guide regarding course of action in such a condition neither any study to substantiate the risk involved. Optimum anticoagulation, endocarditis prophylaxis and optimum interval between the two procedures are areas to be defined as our experience with similar cases increases. Our case emphasizes the importance of multidisciplinary approach and management of such patient at high volume centers.

Initial Poor Function and Primary Nonfunction in Deceased-Donor Orthotopic Liver Transplantation Maintaining Short Cold Ischemic Time

BACKGROUND

Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF).

METHODS

A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF.

RESULTS

From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF ( P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases.

CONCLUSION

Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.

A Rare SOL of the Liver: Diagnostic and Management Dilemma

Aetiology and clinical presentation of space occupying lesions (SOL) of liver are varied. It can be solid, cystic or heterogenous. Usually liver abscess presents as a symptomatic cystic SOL in a sick patient. Here, we are reporting a case of giant liver abscess presenting as simple benign cyst with corroborative image findings of simple cyst. He had significant co-morbid illness and jaundice on clinical evaluation. Liver abscess was not a differential diagnosis from clinical history. None of the haematological and biochemical parameters were suggestive of liver abscess. It was an intra-operative surprise to find such a huge liver abscess with 2 liters of pus, which was drained. We report this case because of its unusual presentation and associated findings.

Occupational noise exposure and hearing levels

A study was made at the Bhabha Atomic Research Center to measure the hearing levels of persons working in a noisy environment. Two different workplaces, central air-conditioning plant and glass flowing shops, where a number of persons were exposed to noise levels exceeding 85 dB(A) were chosen. The occupational exposure to noise was determined using a sound level meter, an octave band filter and a personal noise dose meter. The hearing levels of persons exposed to these high levels of noise and a control group not exposed to occupational noise were measured by means of a pure-tone audiometer in a specially-build booth. These persons, aged between 20 to 60 years, were divided into four age groups for the study. The low ambient noise levels in the booth were measured using correlation technique since such low signals cannot be detected by an ordinary sound level meter. The audiometric findings and the results of the noise level survey are discussed in this paper.