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OK. Yeah, you're live. Perfect. Good evening everyone. Thank you for joining us for our Steer Virtual Journal Club. Uh My name is Hannah, I'm a member of the Steer Committee and one of the project developers. And we've got a really uh great journal club lined up for us. So we are going to um kick things off with um Malacca Jonna who is a um one of the senior clinical fellows in H PB at Adam Brooks. And he's gonna talk us through um a critique of the Waterfall trial um which is a recently published um of or moderate fluid resuscitation in acute pancreatitis. And then we're gonna hand over to Heel who is a Post CT fellow um and co chair of the Steer Committee um in HPV as well. And he's going to talk us through um HPV Trauma for General surgical trainees. And during the talk, um please be interactive with us, ask questions along the side. Unfortunately, you can't um uh ask those questions yourself, but I can ask those questions on your behalf and we're gonna um kind of interrupt the speakers when it's appropriate to ask on those questions to make it nice and interactive. So I will hand over to Malacca now who's going to talk us through the waterfall trial? Thanks very much, Hannah. Um I'm gonna share my screen now. Bear with me for a second. Mhm. Can you see ma'am? Can you see the screen? Yeah. Yeah, we can see that. Yeah. OK. All right. Um Thank you very much and thanks for that uh kind introduction and um thanks to the um the uh committee for giving me this opportunity to talk today uh about this very interesting um paper um that goes by the name Waterfall Trial. Um And it's the title is Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. This was published in uh the new in New England Journal of Medicine in 2022. Um And it tries to answer a very pertinent question for us. H BB surgeons as well as general surgeons. Um That's in adults with acute pancreatitis. Does aggressive fluid resuscitation, reduce severity of pancreatitis or not? Um So, um the, the paper uh first talks about this background of, of course, we know that acute pancreatitis has a very high um mortality and morbidity. And this, the moderately severe rather severe pancreatitis is about 20%. And if you combine moderately severe and severe both together, it's about 35% of this figure is quite important in this study. Um The, the basis of this fluid resuscitation principle is uh on the fact that when you've got pancreas going into a very inflamed state. It ends up being hypoperfused and that is directly proportionate uh uh to uh the possibility of getting it necrosis. And uh animal studies have shown that if you resuscitate with fluid and this can be reversed, hyperperfusion, at least can be reversed and the chance of necrosis will go down. Plus, um there is this understanding that um the acute pancreatitis produces a lot of inflammatory mediators that get in, that get into the circulation, that results in a lot of systemic manifestations involving the the heart kidney lungs and so on. And fluid resuscitation would drive uh uh them or rather flush them out. Um So this is the basis of why we aggressively resuscitate fluids in acute pancreatitis. But there is emerging evidence that suggests conservative fluid strategy is not harmful. That's one aspect. And also there is suggestion of harm uh in multiple systemic res and metal on aggressive fluid therapy, uh not just on pancreatitis per se but on critically unwell patients, we know for a fact that when you um aggressively resuscitate fluid, it brings about harm. And uh there have been some system, systematic reviews and meta on this particular aspect when it comes to pancreatitis as well. And uh that has suggested the same. But despite all of that, we continue to uh practice aggressive fluid resuscitation. Mostly this is mostly because the guidelines currently um still um endorse this. So the waterfall study apparently was carried out to try and provide some high quality evidence to address this practice and its potential harms. So, um, there is a multicenter or parallel group, randomized controlled superiority trial. It's a handful. Um, so it's superiority trial. It's not, it's not, uh, noninferior. So it's trying to say one arm is better than the above rather than say one arm is, um, at least not as not worse than the other. Um It's open label. So it's unblinded to both patients and investigators. And I'll talk about that in a little while. It's done over 18 centers in four different countries. India, Italy, Mexico and Spain. Um from May 2022 September 2021 they had a very robust inclusion criteria and exclusion criteria. The inclusion criteria suggested that they only included people more than 18 years. And also very importantly, when patients presented to the emergency department within 24 hours or uh from the onset of pain or within eight hours from the diagnosis of acute pancreatitis um that, that is when they included the people. Uh So they basically, if the diagnosis came after eight hours, they excluded. Um and then in the exclusion criteria, uh again, very important point is that they excluded the moderately severe and severe pancreatitis at baseline. When the, when the patients presented with features suggestive of shock renal failure or respiratory failure at the outset, they excluded that. Um and apart, so basically what they included was mild pancreatitis cases just to go on to see whether they would develop uh uh severe pancreatitis. Apart from that uh cardiac failure, electrolyte abnormalities, um chronic pancreatitis, uh chronic renal failure, um decompensated cirrhosis. Um and also people who have uh comorbidities with life expectancy, less than one year, all of these uh categories were excluded. Um And that, that has some uh important point as well, which I will talk about when I talk about the limitations and stre um strength. So um the study design uh was based on a, a trial protocol that followed the spirit guidelines, adhering to the Helsinki Declaration principles. Uh The data and safety monitoring board uh uh plays a major um uh part in the study uh that I will mention in a bit. Um And that was comprised of clinical pharmacologist, gastroenterologist, and the cardiologist. So it was done as a randomization, as I said, like uh before, it was a computer based uh randomization, 1 to 1 ratio to uh for the accuracy versus moderate fluids. Uh The two arms randomly, they um uh uh allocated on a 1 to 1 ratio basis. Also uh to reduce confounder, they stratified um the study population into three categories um based on the trial center, presence or absence of c and presence or absence of baseline hypovolemia. Now, that was done to reduce the confounds because whether cer or baseline hypovolemia itself had an effect. Uh uh uh for the development of severe pancreatitis. They won't find that out as a subgroup analysis. So they did that. Um This is the fluid resuscitation protocol, very um stringent protocol. Um There were two arms, the aggressive fluid resuscitation arm. Um They would give a bolus of 20 mL per kg at zero hours followed by an infusion of three mills per kg per hour. The moderate fluid resuscitation arm, they would start off with an infusion of 1.5 miters per kg per hour. But they would give a bolus of 10 mL if uh per kg, if the patient was found to be hypo volumic at the outset. Um So that was a key difference. Um And then there were clear safety checkpoints. Um And this study has these safety checkpoints all over and this plays a major role uh in the outcome of this study as well. So, so if they found that at three hours, if there was a suspicion of fluid overload or decrease, if there was a suspicion of fluid overload, they would decrease or stop the infusion. That was common to both THS and then um at 12 hours, 24 48 hours and 72 hours, they have a very clear goal directed therapy checkpoints. Uh That is if they figured that patient was having hypovolemia on the aggressive fluid resuscitation arm, they would give a bolus of 20 mL per kg followed by three Millers per kg, similar to what they did at zero hours and they would give an additional boluses if the patient was oliguric or hypertensive, similar thing happened with the moderate fluid resuscitation, but the bolus size bolus volume was 10 mL per kg. And the infusion was 1.5 mL per kg bar. And if the patient was all uric or hypertensive, they would give additional boluses at these checkpoints. If they found that the patient was normal anemic, they would just carry on with the infusion of 1.5 mL per kg power. And that was same to both aggressive and moderate arms. And the main significant difference is that uh the aggressive fluid resuscitation, they would continue uh fluid resuscitation for 48 hours and then would only stop at that point. Whereas in moderate fluid resuscitation, they would stop at 20 hours. Um So that was the very clearly laid out plan. Um The following factors were common to both thumbs. They resuscitated with ringers lactate. They did not mention any other fluid that they used. Um just ringers lactate was the only thing that I could find. Um the fluid rate uh was like I said earlier there, if the reviews are stopped, if there was evidence of fluid overload, uh there were clear definitions of volume state they provided. And uh another thing they did was about oral feeding when to start oral feeding. Now, this is always a, a question that comes to our mind. Also with pancreatitis. So they use this pen promise um um um scale which is a patient reported outcome scale. So if the, if the panic scale was less than five, they would uh uh start oral feeding. So this basically contains seven different types, seven different symptoms, pain, abdominal distention, difficulty in eating nausea, vomiting, thirst, body weakness, and uh the uh bowel movement problems. So they were all scale from 0 to 10 each. So it would be a scale of 0 to 70 the span promise score. Um And if it was less than five, they would start oral feeding at 12 hours, that that's what they did. And then they had clear me outcome measures uh mentioned the primary outcome was to find out whether there was a development of moderately CV or CVA pancreatitis. And this was based on the revised Atlanta classification. So just to uh recap um the revised Atlanta classification and that is at least have one of the following criteria, whether the patient had local complications like fluid around the pancreas or uh thrombosis of blood vessel and so on. And then exacerbation of a preexisting coexisting condition or if the patient's kidney or the heart or the lung got affected, then you would call it moderately severe. And if that continued for more than 48 hours, that would be severe pancreatitis, that's how they defined it. Um Then they clearly defined a safety outcome. This is very important in this study and that is the development of fluid overload. So, um they wanted to find out uh you know how many patients that would develop fluid overload. Um So they defined fluid overload uh is two out of the following three symptoms, signs on and radiological evidence of hypervolemia. If you have two out of these three, they would call it patients being fluid overloaded. Um They excluded the s pleural effusions both uh as from fluid overload diagnosis, pleural effusions, mainly because in acute pancreatitis, you know that most of the acute pancreatitis patients would develop some amount of pleural effusions and they are exudative and they are not related to the um the the transudative fluid overload. So they excluded that that was a, that was a good thing they did. Um And then once the diagnosis came, they divided into mild, moderate and severe uh the fluid overload uh based on the response to medical therapy and uh that there was evidence to say that hydration was decreasing and if the PF ratio was more than 300 in. So that means to say the lung is not really affected, they would call it mild. But if the PF ratio is less than 300 at any point, they would call it moderate. And if the patient went on, went on to be ventilated or needed filtration for that matter, they would call it severe um then clearly defined uh secondary outcomes. Um They wanted to find out whether there's any statistically significant difference between uh these different, different outcomes and promise scale. At each checkpoint, they won't check at each checkpoint CRP at 40 at 72 hours. Um organ failure, local complications, length of stay, I see, stay need for invasive treatment, need for nutritional support and mortality. Uh So as you can see, there are quite a lot of uh outcomes uh variables. They, they want to check the statistical significance where the multiplicity correction for multiplicity comes. I will talk about that in a little while because they couldn't do it right. Um Going to the statistical analysis, they clearly mentioned the power calculation um with very good uh uh data uh uh or rather information uh provided as to why they had this power calculation. So I told them earlier, they got this 35% as the percentage of moderate to moderately severe or severe pancreatitis patients that was based on a Spanish multicenter cohort study. So what they wanted was to bring this number from 35 to 25 as a primary outcome point. And um in order to get that, the power calculation suggested they want to recruit, they had to recruit 744 patients uh and 372 would go to each arm. Uh And that was how the, how the study was planned, alpha was placed at 0.05 and the power was placed at 80% which is four times that of alpha. Um The, the, the, the analysis principle was intention to treat rather than per protocol uh which is, which is good because this is a superiority trial. Um And then comparison of categorical variables was done with C square F exact as appropriate continuous variables. They use student T and man with you. And um I said earlier about the stratification of groups in the randomization, they did, you know to reduce the confounding. Uh They won't do a post hoc analysis of that uh uh with this particular method called Coleman hand method. And then they, they, they wanted to do the P value assessments on uh um almost all the outcomes. Uh but most of the time, most of the uh uh the outcomes were expressed as relative risks with 95% confidence intervals uh which I tell which I will tell in a bit as to why that happened. Uh Right. Um So they planned this study in such a way that they wanted to do two interim analysis before they reached uh the, a complete number of patients. Um So they did two intra manner. They wanted to do two in two intra manner is when one third of the population was reached and then two thirds of the number was reached. So at 248 and 496 respectively, there were three very well defined uh priori stopping rules. Uh basically hard stops. Uh if primary outcome was reached at first interim or second interim at these given P values, they would stop the study. Uh If there was any obvious, if there was clear evidence of harm in any of the groups or any of the group or the other, they would stop it and then slow recruitment rate um was the third one. So these were the hard stops. Uh And it turns out that it actually did uh reach a uh the study by the data and safety uh uh Monitoring board at the end of the first analysis, uh because there was significantly worse results with respect to safety outcomes in the aggressive resuscitation group. Um And that was unfortunately not balanced by any trend to the improved outcomes in that particular group. Uh So they had to stop the study. So uh to go to the results, uh go through the results of 676 patients they started off with and they checked the eligibility. Um and then found 249 were selected uh after the exclusion criteria and they Rando randomly categorized them into uh assigned them into the accuracy group uh and moderate group 122 and 127 respectively. Um And these were the uh the characteristics at baseline. Um Now, these are the, the uh category of data um going through the representativeness of the real world um sex and the cause of disease were representative of true acute pancreatitis. Um But when it comes to age, this cohort had low uh sorry, younger age group. Uh reason probably being because they, they excluded all these coexisting conditions in adults uh which would usually be associated with older age. So you ended up with a uh relatively a younger uh population, although this might not be a limitation per se, but this is, this is a study characteristic um volume administration. Um It showed that the aggressive resuscitation group received a median of 7.8 L uh during the 1st 48 hours. Whereas the moderate resuscitation group only received 5.5 L. And the greatest be between the group difference was seen in the 1st 12 hours where the fr group received 3.4 and the moderate group re uh received 1.5. OK. So to get to the front, uh which is to see whether patients would go on to develop moderately severe or severe pancreatitis and whether there's a statistically significant difference in any of these arms. They found that there is no significant between group difference um in the development of moderately severe or severe acute pancreatitis with ap value of 0.032 going through the secondary outcomes. They could not um do the P value analysis or significant analysis of this. So they, they only managed to get the uh percentages and then provided the um 95% confidence intervals with a uh risk, a relative risk on these um So the secondary outcomes, the persistence icu admissions, respiratory failures, death, and all of these um there was no significant difference between the groups, but clearly there was a trend towards favoring moderate resuscitation as you can see with these percentages. But the most important thing is that the safety outcomes um they found that aggressive fluid resuscitation was associated with a very significantly higher incidence of fluid overload than the moderate fluid resuscitation uh that you can see with the P value. Um And this became the um this basically put a spanning in the words um uh and stop the trial. Um And um quite interestingly going through this chart, uh One additional thing you can find is that although so the fluid overload, they defined as two out of three symptoms, signs or radiological findings. And if you go through the radiological findings, that image evidence of fluid overload does not show a striking difference between the two groups. But I think that is because they, they had this early recognition and treatment of fluid overload to prevent uh patients getting worse outcomes. So image findings would not crop up. And that's probably why this happened. Although they did not mention that in the paper, but I think that was the reason. Um the, they did a subgroup analysis, as I said earlier because they want to uh check the confounder here. Uh And the subgroup analysis also showed that there is an increased risk of fluid overload uh in the aggressive resuscitation norm uh in all the subgroups uh of patients. So, at baseline with or without patients with hypovolemia, they found that when you aggressively fluid resuscitated in any of these patients that you still ended up with uh uh fluid overload. So all of this did uh uh was the DSM B ended up stopping this trial uh because they couldn't balance uh this couldn't be balanced by any trend towards the improved outcomes in the uh the aggressive resuscitation group. Um And they said that for the trial to reach primary and secondary outcomes, um the data and safety Monitoring Board felt that a large recruitment would be required that would place patients at home and that's the reason why they had to stop it. So the conclusions uh the show that aggressive recess increased the risk of volume overload. Um Secondly, most episodes of fluid overload were not severe. But uh that was probably because of the early detection and treatment that was by, by default, by the design of the trial. And that is one of the reasons why you would not see these image findings of fluid overload. Um Trials showed no improvement in primary and secondary outcomes when you consider the two arms, the aggressive arm and the moderate arm and given the data showing increased harm uh without improvement in the primary outcome, the DSM B unanimously recommended that the trial be stopped. And um and these findings do not support current management guidelines is what they have said in the paper which recommend uh the current guidelines recommend early aggresive resuscitation for the treatment of acute pancreatitis. Um They also went on to say that aggressive fluid resuscitation was associated with a tendency toward a higher intensity of symptoms, longer duration of hospital stay and a higher incidence of necrotizing pancreatitis than moderate fluid resuscitation. So it's a tendency towards uh these because they couldn't come up with significant le levels. Um And then they mentioned that the waterfall findings would add to the growing evidence that aggressive hydration is linked to worse outcomes in critically ill patients, which is something that I initially started uh said at the, at the outset of this presentation, right? So the, the, the paper published some limitations which I will go through in a bit when I talk about strengths and limitations of this study. Um So I will try to go through the strengths and limitations in a uh uh in a manner that that follows the paper. Um I thought that would be appropriate. Um So I thought the the abstract, although I did not mention anything about the abstract, it was a very clear abstract that was representative of the paper. Um That was a good one. The background, of course, they did a uh the, the research title here is a clear, the it was, it represented a clear research question because we still adhere to the fluid accuracy, fluid management, which is guideline driven. Um And they wanted to find out whether this is there's actually a uh a true benefit of this. Um And I think that was a clear research question that they uh they clearly mentioned they had done a uh an, an appropriate literature survey. Um They found conflicting evidence uh from uh different studies. Um One study said that there is no clear benefit And another study said actually there is a clear benefit. So they, they have done an appropriate literature survey based on that. But however, I found that there was this particular meter that was published in 2020 that is more than 2500 patients and that was not really coded in this study. Um And I found that was uh a bit strange because this was published in 2022. And that particular meta analysis basically came up with almost all the same things that this study said that aggressive fluid recess really did not bring about a benefit and there was more harm than uh benefit. Um going through the methods. Um Clearly this research question requires an interventional study. So the randomized controlled trial is the the appropriate study for this, however, making it open um without blinding. Uh I think that's prone to bias. Uh The problem here is that you can't really blind, especially when it comes to the uh the the investigator or the physician side. Of things because the physician had to assess the patient sequentially to titrate fluids accordingly. But I wondered whether the patient could be blinded at least. Um, because our patients, you know, most patients wouldn't know which fluid rates they are getting. Uh, it's not really, um, a major issue there. So I'm not really sure as to why they didn't make it single blinded, um, um, Multicenter trial. Um, clearly that was a strength. Uh However, majority was coming from one country. Interestingly, um 86% of patients were coming from Spain and they did not specify this in the manuscript. Um I only figured that out through the supplementary data. Um clearly stated primary and secondary outcomes, clearly expressed safety outcomes which obviously put a stop to the trial. But I think that safety outcome expression was very important uh because I it was a crucial checkpoint that follows human research principle. Do no harm is the single most important thing. So that was required. Um inclusion and exclusion criteria were clearly mentioned here, but um the exclusion criteria as I told earlier was very significant. Um So they excluded a lot of patients. Um And um I there clearly is evidence of selection bias, even the the paper suggested that there would have been biased because of this extensive uh exclusion. Um And what that leads to is a poor representation of the spectrum of the disease in the real world. Uh Still going through the methods, robust study design for sure. Um randomized control guidelines was adhering to the Spirit guidelines. However, if I were to pick the Spirit flow diagram was not there in the main manuscript which I found was a bit difficult to follow through. So I had to get to the um this supplementary uh things you usually see the Prisma, the consult uh guidelines on the paper. So that was not there, that was not there. OK. And then um well defined fluid recess protocol, which was a very good strength, obviously. But this is something they also mentioned as a limitation. They wondered whether aggressive fluid resuscitation may have been too aggressive because they mandated 48 hours in the aggressive uh uh resuscitation group uh for patients to get 48 hours at a stretch fluids no matter what. Whereas the moderate resusci group, they stopped it in 20 hours. But because this is, this probably will not represent the real world practice. Um So I think there's a limitation there prespecify definitions. Um they were very good and that because of that, uh this improves the internal validity of this study. Um And they, oh, sorry, I think I'm running out of time. Uh just a couple of slides more um remove of clinical sign. And so they, they in order to increase the or improve the into observer variability. Uh Sorry, my bad. They in order to remove the into uh observer variability and improve the reproducibility. Um They removed some clinical uh uh uh findings. For example, some studies were looking some, some centers were doing these S3 S four heart sounds to check whether the patient was developing uh fluid or, but that's so a variable thing. So they removed that. I think that was a good thing accommodated confounder, which was a good thing by stratified uh stratified randomization going through the analysis. It was a very good power calculation had relevant information provided. But I think this was also a limitation here because they want to bring down the percentage of acute pancreatitis severity from 35 to 25 which I feel might have been a bit unrealistic, which made uh uh the study a bit difficult. There was no loss to follow up intention to treat analysis was used. Um And I just mention what in in in this slide as what intention to treat analysis is. I presume everybody knows that once randomized always analyzed is what intention to treat analysis is. And there are good strengths in it, especially in a superior trial because it replicates what happens in real world because patients will be lost to follow up will not be compliant. Um And you will still be taking the same number of patients that you started off till the end of the analysis. So that replicates the real world scenario, it prevents the bias uh when incomplete data is taken out, uh preserve the baseline balance between groups preserve the sample size, which is very important that maintains the power of the study and minimizes the type one error. So there are good things about uh uh uh sticking to intention to treat analysis here and then going through the results, uh one more time balance baseline characteristics. However, we saw that younger age was seen uh as opposed to the proper acute pancreatic spectrum that you see in the world, Uh a appropriate statistical test and the presentation was a good thing. Uh But then the, the achy seal of this trial was that it was terminated early because of the uh because because of the um the safety outcomes and therefore, uh the study is under powered. So the, the authors have acknowledged this um secondary out endpoints, they couldn't successfully test um because the study terminated. So they, they couldn't do this correction of M correction for multiplicity. So whenever you have multiple significant tests are carried out uh in a study increases the type one error. So you need to do this point for any correction, but they couldn't do it here. So the secondary outcomes do not have P value. So they have categorically mentioned, do not uh this because of this, they couldn't infer treatment effects of the secondary outcomes and that's a limitation of the study. Um And I feel uh if the, the, the they said that there's a trend towards benefits of moderate fluid resuscitation in patients with acute pancreatitis and uh they could have reached statistically significant levels if the study was not terminated. So the last bit is the discussion. Um So because the study ended before the recruitment of the originally planned sample size and the sample size, they want to reduce 10 by 10% of the severity of the pancreatitis cases making a statement saying there's no improvement in the primary outcome or secondary outcomes by aggressive fluid resuscitation. Based on that data, they extrapolated from the sample size that did not meet the original power calculations. I'm just wondering whether with one can argue whether this is really represent the reality. Um But study does answer very clearly the question as to whether aggressive resuscitation brings more harm and it adds to the growing evidence. Um and the bottom line is waterfall provides a robust evidence that high volumes of fluid administration leads to fluid overload. And this is something that we should really uh consider in our practice uh because we continue to resist it with aggressive fluids uh for our patients. The current guidelines B SG says a rate of 5 to 10 mL per K GP until the recist goals are reached in the American Journal of Gastroenterologist uh in their guidelines in 2024. They say they say there, there are two important things. They say. One is there is a general consensus that treating a patient with mild disease early in the course of the disease with early aggressive or moderately aggressive hydration is beneficial. So they also endorse on the aggressive fluid resuscitation. They also say that negative studies, the studies that actually found that these aggressive ones are not really good. They enrolled only patients with severe disease or well beyond the time where early aggressive intravenous hydration would have been effective. Now, waterfall, however, really addresses both of these things because they excluded patients presenting more than eight hours after diagnosis and also they excluded severe and moderately severe cases on admission. So, in this study note that shows one out of five that goes on to actually develop severe pancreatitis despite fluid resuscitation does challenge these guidelines. And uh that, that's my last take on this uh on this paper. That's great. Thank you, Monica. That was a really brilliant talk talking through that um study we did have one question raised um which um Annelise has mentioned. Um she said that they didn't mention um or they haven't stated that they've obviously used invasive monitoring to measure fluid overload. And do therefore think it was a bit subjective and how they were, you know, observing um the fluid overload. And she said especially by surgeons looking at the JVP and in more severe pancreatitis, the fluid shifts and dropping albumin could cause peripheral edema without the fluid overload. Yes. And, and whether you think that has any, you know, bearing on, on how they looked at fluid overload in this study. Um I think the, the, the first one, the um invasive monitoring. Um I don't think they mentioned that for sure. Yeah, I think that that would have been a um uh a thing that, because we, we do use invasive monitoring in the ICU uh mostly uh to kind fluids. Um So that would have been beneficial in recognizing people uh who developed uh fluid overload for sure. Um, but I feel they, they had a, a properly laid out plan to identify people and they did find out uh uh diagnosed fluid overload uh before patients developed severe complications. And none of the, the, the this bit I actually did not mention, but uh none of the patients actually did go on to uh be harmed by it. Uh uh The study which was, which was another important thing II mentioned. True. Yeah. Um And Albumin. Yes. So that, that I believe is a confounder. Um They're trying to address one element of it uh by saying they want to exclude um the PPL effusions from this uh albumin. Um I'm guessing. So, so when they said symptoms and signs, uh they did not specify what specific symptoms and signs in the study per se. Yeah, in the manuscript. Um So low albumin and fluid resuscitation that really confirms matters as well. So I think, yeah, that's a very valid point uh that they did not mention. Yeah, that's, that's, that's a good one. Yes. And and I have a question for myself. Um I, I've worked with um bosses who have a specific idea of their fluid resuscitation, they'll say 246 bags for acute pancreatitis, um hourly bags and things like that. Uh And I'm sure that other people have had that experience before from this paper in terms of you guys working at HPV UNIT. How, how do you manage patients with acute pancreatitis? Do you er, on more aggressive fluid resuscitation or moderate fluid resuscitation after this paper? Well, I think after this paper, uh I think this paper is an eye opener uh for all of us. Um And very recently also we had a couple of patients uh just in front of each bed. Actually, those two patients were included over. Uh um So, and, and we actually followed um sign symptoms as well as um radiology. All of that. We, we followed that protocol basically to fi figure out the patient was in fluid over and we actually stopped our resuscitation. So we've, I think we've been doing this to a certain extent uh uh the aggressiveness of our fluid resuscitation. Although in the ed, when the patient comes and you, you diagnose acute pancreatitis, the tendency is to give a massive amount of fluids. I think that still happens in HP. What happens is most of the time these patients are handed over to us the next day. So we usually do miss this crucial 1st 12 to 24 hours of these patients. So it's, it's actually beyond our control there. Uh But I think it's, it's a, it's an eye opener for all of us uh to look into the development of these uh um fluid overload symptoms because some of these patients can develop fluid overload very rapidly as opposed to some developing uh one or two days down the line. So, uh I think, I think we, we, I for one would consider uh that at least having more fluid resuscitation rather than a uh would be beneficial in our case because we have seen fluid overload quite a lot of times. And most of our patients sometimes are, this is the problem as with this uh uh uh paper also because they excluded all these heart failure patients. But our patients are heart failure patients or, or already they have chronic renal failure and then, then they developed this and how can we uh uh carry out the aggresive fluid resuscitation anyway. So in such situations, we actually do uh uh become conservative in our fluids. So I think partly we are we we practice a very pragmatic uh uh uh or a very sensible approach in managing fluids. But like I said, in the 1st 24 hours in HPV, based on how, how we practice our set up, we are not privy to the the patient's management because the 1st 24 hours, yeah, I think this is, this is a good study that would open everybody's eyes. Yeah, I think it's a great study because obviously we, how many pancreatitic do we see on our takes? And we opened some polls um during the talk as well, saying how many people, um, do you feel, how many people do you generally see with, with treated for acute pancreatitis that go into fluid overload? And the majority of people said occasionally, often or, and then a few people said often and very often. But then we also asked the reverse of that and said, how many people do you see that aren't adequately fluid, fluid resuscitated. And again, people are saying 63% of people said occasionally as well. So it's, we're seeing things still going both ways. Yeah, some people aren't getting enough, some people are getting too much still. But, um, that was great. Well, we'll move on to Hamil now. He's going to talk us through um HPV Trauma. Um And again, any questions, just fire them in the, um, board on the side and we can ask them as we go. Can you see my screen? Yes, we can. Excellent. Good. Uh, good evening everyone. So, um, I thought for the second part, I'd give an overview of H PP trauma because it's something that uh we will see in general surgery, but don't necessarily have the opportunity to know the nuances of how trauma is managed and, and follow these patients up. Once we've seen them on call. Um HPV trauma is, is challenging um mainly because of the anatomical complexity um and unfamiliarity with certain parts of the abdomen. Um but regardless of the grade of injury, um the outcomes can be really good. Um but that's largely based on a good clinical assessment, having um the right imaging to hand and having access to A HPV center, either to transfer the patient or at least get advice. So I'll start off with liver trauma because this is the one that we see most common um and can also be quite serious and even pringle recognized that. Uh although although rare in the grand scheme of things, it can be a serious condition um for the patient. So the liver is the most frequently injured organ in abdominal trauma. And because it's a highly vascular organ, there is a potential for massive bleeding from it. Um which in itself exacerbates the the the triad of death of coagulopathy, acidosis and hyperthermia, er and increases the risk of death. Um And in fact, uh over half of patients who die from liver trauma is because of major hemorrhage. The there are two main mechanisms. Um blunt trauma, er makes up most of the uh the the types of liver injury, er, usually RTA S um but penetrating trauma, er such as gunshot wound and stabbings can also occur but less. So in the UK, in South Africa, it's actually the other way around. Uh unsurprisingly, um blunt trauma, there's two types of blunt trauma that occur. There's a deceleration or shearing injury, which usually occurs with RTA S or fall from a height. And this is when you've got um a, a rapid er forceful movement of the liver in relation to its fixed ligaments. Er and this leads to parachma injury and with a deceleration injury, you, you, you, you most often get uh a shearing or a laceration between the anterior and sector and the posterior sector. So between 58 and 67 or between the left and right, er, the plane of the left and right lobe, so be between four and 58 as well. And then the second type that you er, of blunt injury is a crush injury which is direct trauma to the liver. And here you typically see injury to the central, uh central lobes, er segments of the liver. So 45 and eight, the caudate lobe which sits behind at the back uh is often also injured in a crush injury because it's, it essentially gets compressed against the spine. I'm not gonna go into detail about the American classification of liver trauma cos I'm sure you all know it or know of it. Um, but essentially 1 to 3 is classed as minor er, liver injury and, and represents er, increasing depths of er, er, er laceration or increasing size of subcapsular hematoma uh and the severe er injuries which are grade four and five represent uh greater disruption of, of uh an entire lobe. So, uh grade four is up to 75% of a liver lobe uh disrupted and grade five is more than 75% and six is where you've got complete avulsion of the liver and that's just not compatible with life. Um So this schematic diagram represents uh the grade. So you've got increasing depth of laceration as you go from 1 to 3, increasing size of liver lesion, uh liver, er subcapsular hematomas. Um four, you've got a more of a major disruption and five most of a, a liver lobe is disrupted. Um And if you, if you, what these look like on CT, so here you've got, these are both the same patients. So you've got a uh lacerations are seen as these Hypoattenuating er irregular lines. Um So you've got a laceration uh just here on the left. Um And then um er subcapsular hematomas are, are seen as these, these again, Hypoattenuating sort of lesions. Um So this is a, a grade one or two at most. Um But on the other end of the spectrum, you can see here there is almost complete disruption uh of a major uh liver lobe. So this would be a a at least a four, if not a five. So to diagnose a liver injury, you obviously stick to the atl S principles of resuscitation. Um If someone has a penetrating injury anywhere in the abdomen or the lower chest, then you should have a high degree of suspicion. Um, as with any trauma, the patient may be hemodynamically unstable, not responding to resuscitation. They'll present with abdominal pain and distension, shoulder tip pain because of phrenic uh irritation, you'll see a typical pattern of bruising and a seatbelt sign if there's an associated bar leak, um, they may develop perit bitter peritonitis. Um, a lot of these patients may also bleed into their bile ducts, um which then that blood clots off and causes obstructive jaundice. They may, if you have a patient who's jaundice and has features of an er, I believe that would, that should make you think about hemobilia and therefore a possible liver trauma and you get a transaminitis as well because of the parenchymal disruption. Ok. When it comes to imaging, um we know about the fast scan from ATL S. Um uh it, it, it, the problem with, it is not particularly specific, it just tells you about the presence of blood and even then it doesn't tell you there's blood, it just tells you there's fluid. Um uh it gives you no indication about the severity of the injury or any vascular involvement. There's a high false negative rate over 40% and it is operator dependent. It doesn't tell you a lot about the retroperitoneum um and its sensitivity uh reduces with obe with obese patients. Um So in this, in this snapshot, you can see what a typical fast scan with a potential liver injury looks like. You can see the kidney liver and the and this black line, there's a bit of free fluid between the two suggesting in the context of trauma that would make you think about blood and blood from the liver. Um So really there's gold standard is CT scan, it has a, a sensitivity of 95% and an even higher specificity for liver liver injuries. Um You want both an arterial and portal venous phase um to assess the liver which which all trauma, all sort of trauma pan scans come with. Nowadays, the arterial phase is really to help look for any active arterial bleeding. Um and the portal phase is to is to enhance the portal vein, hepatic vein and the parenchyma. So the parenchyma enhances better with the portal venous phase. And therefore you see the actual injury better on the portal phase. So here's an example of the importance of the two phases. So this is an arterial phase, this middle shot here. So this this is a blush of contrast you can see um which will tell you that there's some active bleeding within this hematoma. Um And if you, if we look at the portal phase, so this is the arterial phase first on the left. So you can't really see an awful lot here, but it's only when you go onto the portal phase, you actually see the laceration much more clearly. So this shows the importance of having the portal phase as well as an arterial phase. Um, in terms of management. Er, so the lower grades, which is what most liver traumas are, er, mostly can be managed, er, conservatively. Um, and the higher grades, uh, about a third of them can be managed conservatively but, but often they end up in theater. Um, I'm very reluctant to classify management based on grades. Er, it's really dictated by the clinical status of the patient and how they respond to resuscitation. Um That will tell you how invasive your, your treatment is going to be. In terms of non operative er, management, most liver injuries will stop bleeding uh spontaneously. So the indications to manage someone conservatively would be uh uh a patient who's hemodal stable or at least responds to resuscitation, er, and no other indication to take the patient to the theater. So, free air er, or peritonitis and the principles are that you need um you need a critical care setting. Um, so at least a HD U to monitor a patient serial examinations, you need to monitor hemoglobin and the hemodynamics, good analgesia. And if that means a PCA, then so be it, um you want to make sure that they can, you know that they don't need to split their diaphragm and you know, develop atelectasis and chest infections. Um in terms of Delta pin. So it trauma patients are in a hypercoagulable state for the 1st 48 hours. Um, so there's no reason not to give, er, prophylactic Delta Pa in. There's no such thing as I know they've just had a trauma risk of bleeding prophylactic Delta Pa in. Absolutely, you should start patients on. Um, and, and in fact, pe is the third most commonest cause of death in, in trauma patients as a whole. So, it, it's, it's vital, they have some prophylaxis against that. Uh Nutrition equally. If there's no contraindication, you can start enteral nutrition. Um I in these patients er, and mobilize them early. Um This whole thing about bed rest, there's no evidence to show that mobilizing an a a patient early, had at least any secondary bleeding. So um uh absolutely immobilize them early if they can, if there's no other, obviously, liver injuries and things um with, with regards to re repeat scanning in these conservatively managed patients, there's no actual consensus guidelines on whether or it or how often you do an interval scan. Um In fact, the world's scient of emergency surgery guidelines say that you don't need to, unless it's clinically indicated at Adam Brooks, we do a triple phase CT liver. So that's an arterial phase, a portal venous phase and a delayed venous phase. Uh we usually do it around 48 hours and then a week later, if the, if the patient's stable, but if at any point, the patient deteriorates or wobbles, then we do it sooner to look for any active bleeding. And really what we're looking for at the interval. Scans are the development of any pseudoaneurysms um or any, any bilomas or, or collections, er or any evolving ischemic injury that might be heading towards turning into abscesses. Er So that then, then you know that this patient might need an embolization of pseudoaneurysm. So before they start bleeding from it or any drainage of any collections, um a couple of words on embolization. So most guidelines have actually now incorporated embolization as part of their conservative treatment protocols. Um and it's really used if you see any active bleeding or a blush on, on CT or a pseudoaneurysm, um the patient should be stable. I put that in, in inverted commas because um uh I think the indication for embolization has, is, has widened and continues to widen. And actually, if you've got a patient who's a bit tachycardic, a bit underfilled a bit hypovolemic, but they're not in extremist, you can probably take them to the Angio suite, er, and they do quite well, er, if they've been embolized successfully and a lot of centers now are using er super selective embolization. So you're not actually having to embolize um named er arteries that, er er upon which the blood supply to the liver, er relies. Um If you do have to embolize a named artery, then it, it's, it's not ideal, but obviously, as you know, you've got the portal vein supplying 70% of the liver. So it's not the end of the world. Um And if, if embolization fails, then you, you need to be thinking about taking the patient to theater. Um just to show from a radiological perspective, the difference between active bleeding and a pseudoaneurysm. Um So an active bleeding, this is the arterial phase on the left. So you can see the contrast blush. Um this is now a delayed phase and the contrast is still there. So with active bleeding, you don't get wash out of the contrast on a delayed phase and that tells you that there's active bleeding. Um And this is, this is how it looked like on an angio. Um So you can see the blush here and after embolization, it's uh it's completely stopped. Whereas in contrast to pseudoaneurysm, which is a false aneurysm. So it's a hematoma that's connected to the uh to the vessel. Um on the arterial phase. Again, it looks a bit like a blush but it on the delayed phase, it washes out. So that this tells you it's a pseudoaneurysm rather than an active arterial bleed or a blush. And you can again see it on the angio uh and that can be embolized in terms of operative management indications would be heat instability, any peritonitis or any other injuries requiring a laparotomy penetrating trauma, especially if it's a high velocity gunshot wound, uh would be an indication as which is part of general trauma principles really. Um Or if the patient has failed conservative management, um then that would be a reason, but it's important that you have adequate blood products, the right diagnostic facilities, the right surgical expertise and itu back up as well. Um And absolutely see, case would be advice early, um especially if you're thinking about taking a liver trauma patient to theater. So in terms of set up, um, so you would uh position the patient like a standard trauma laparotomy in a, in a crucifix position, neck and knees, uh prepped and draped, gives you access to the chest as well as the abdomen. Um, er, use a table mounted retractor in Adam Brooks where we use a Thompson's, er, ask for a general set, a liver set as well as vascular clamps and obviously as with any trauma suckers and lots of packs. Um, if there's no bowel perforation or no bile leak, then you can use cell salvage. Um, so you can ask for that to be ready as well. So in terms of what you actually do in theater, so as as with any trauma, laparotomy suction, blood, four quadrant packing, if you notice minor incidental bleeding in the liver, um then you can use some hemostatic material, some seril um til you know, er, tachosil, um whatever you use, er, or diaformin Argon er, to control it. But if there's significant bleeding, then then uh you need to use the sort of push pull, er, sorry, push pull, push pack, er, pringle t er, sort of er, paradigm. So with push you essentially, you want to essentially gently compress the liver. So you're closing the liver laceration a bit, like closing a book. And the whole idea is you want to restore the anatomical er, position of the liver. And if the bleeding then stops, you can then pack the liver. Uh And if this keeps the bleeding under control, then this suggests that you have a low pressure bleed, such as a portal vein bleed or a or a, you know, a branch of the portal vein within the parenchyma. If the bleeding continues, then the next step is you need to pringle. Um And if you, if you pringle and that stops the bleeding, then this suggests that there's probably an arterial bleed, cos packing doesn't control arterial bleeding. Um Whereas obviously, if you pringle, it will um if the, if the bleeding continues despite a pringle, so you've packed, you've pringle, there's still major bleeding. And this, this makes you, you should start thinking, is this a a bleed from behind the liver? So either a major hepatic vein or, or the IVC um in terms of packing. So as I said, the aim is to restore the liver to its normal anatomical shape. So you want to, you want to release the fixed attachments. So the Fauci form ligament, the left or right ligaments of the liver depending on where the injury is. Um And before you pack, otherwise, if you pack, it just makes the injury worse. Um be gentle. The whole idea is to um uh overcome the portal venous pressure. You don't want to pack too tightly because you will causing necrosis of the liver. So once you've packed and you've got some control, ask the anesthetist to fill the patient up, replace blood warm, the patient et cetera, correct the physiology. If, if it's, if things stay controlled, keep the patient packed, uh put an athera on, send them to itu for resuscitation and bring them back in 48 hours, you can then remove the packs at 48 hours. If there's no further bleeding, then the pack can stay out and you can close the abdomen. Um So this is how you want to pack. So you want to essentially close the laceration. Um You don't want to put packs within the, the the laceration cos that would just make the injury worse. Um I have seen or read people doing this in a mental patch of the liver. I'm not too sure about, I've never seen it myself. I'm not too sure about it. I think the big my view is that the big stitches through the liver will just cause necrosis of the liver parenchyma. Um But um so I'm not, I'm not 100% sure about that. There are some complications of pla packing. Obviously, if you haven't got enough control, the patient will continue to bleed if you pack too tight. Um In addition to necrosis of the liver, you can also compromise cable flow and therefore venous return. And if the packs are left in too long, they've, they're a source of infection, patients get collections, become septic, multiorgan failure. So, pringle maneuver. So this is when you've packed, but you still haven't quite got control. Then you need to do a pringle maneuver. So to do this, you open the less omentum. So the thin film of tissue between the liver and the stomach, um just medial to hepatoduodenal ligament. Um So you open that and that allows you to get a finger uh or a or an atraumatic clamp around the hepatoduodenal ligament that contains the portal triad. Um And the whole idea, again, you don't want to aggressively clamp it. The whole idea is you want to stop the inflow in the artery and portal vein. So you need to compress enough to stop that but not so aggressively that you're injuring, injuring the bile duct. Typically, we would do er 20 minutes on a pringle and five minutes off. Um just to prevent an ischemic fusion injury of the liver and a normal healthy liver can probably tolerate about an hour or so of pringle time might be a bit less than a damaged liver. Um So this essentially shows how to do it. So you open the letter and then this is the free edge here. So it allows you to get a clamp uh or, or a finger across it. Um So if the bleeding stops with a pringle, like I said, that suggests you've probably got an arterial injury and then you, you've got two options. You can either uh call IR to theater if you have, have a hybrid theater. And if it's a distal intraparenchymal vessel that's been bleeding, you can see if they can do an non tablet angio and embolize it. If it's a more proximal vessel that you don't want to knock off, then you can ask them to see if they can stent uh a proximal vessel. Alternatively, there are surgical options to control the arterial bleeding which I'll come onto in the next slide. Um If the bleeding is still not controlled, like I said, this is probably a major IBC or hepatic vein injury. And then you need to think about clamping the IVC above and below the liver um and get total vascular occlusion. Um But as you can imagine in a, in an injured liver, that's, that's not gonna be well tolerated. So, in terms of the surgical options of arterial bleeding, uh so one option is embolization, but the other option is a nearly surgical tendon. So you can just simply suture, ligate a small vessel, clip it. If it's a major vessel, you should try and repair it primarily. Um So if it's a hepatic artery, um uh you, you should try and repair it. But if you can, if you can't, you can ligate it because most of the flow is through the portal vein. Obviously, assuming there's no, you know, portal veins from the secondary to the trauma, et cetera. Um If you do ligate the hepatic artery, you need to make remember to do a cholecystectomy because otherwise you'll get necrosis of the gallbladder. Um, the portal vein, you should try and repair because it, it supplies most of the liver. Um sorry, it provides most of the supply to the liver. Um and er ligating it would risk necrosis and also venous skin you of the bowel as well. Um But if you are going to ligate it, you need to ensure that the hepatic artery is patent resectional deprivement. So this is so this is involving any necrosis, devitalized tissue back to normal living healthy liver. Um And this, this uses er, er, the lines of injury rather than any anatomical brain. So, it's technically a non anatomical resection. And because it's a non anatomical resection, you may end up exposing segmental bile ducts which may be leaking. So you need to make sure you control the bile leak as well by suture, ligating those, the timing for any er resection of any necrotic tissues is, is a bit uh is debatable. There's no real consensus. It would probably make sense to do it at the time, er, at the 48 hour time when you relook and thinking about taking the packs out because that's given the necrotic tissue a chance to demarcate, demarcate itself off. Um, so, you know how much to take formal anatomical resections in the context of trauma is very rarely used, just because it's a major undertaking. The patient is already physiologically, er, deranged. It's really just reserved when you really can't get control from any other way. Um Usually deep lacerations, major blood vessels involved or if there's extensive necrosis or a major hepatic vein, one of the three main hepatic veins bleeding. Um So with, so you've packed, there's no bleeding, there's ongoing bleeding, you pringle, there's ongoing bleeding. So now you're thinking is this blood coming from behind the liver, the IVC or the major hepatic veins? Um Before you jump to that conclusion, it could be that the patient has an accessory left coming from the left gastric or an accessory, right from the S MA. Because if, even if you pringle your, these, these vessels aren't controlled. So you could, so you need to check for those and see if they're bleeding from those. Um uh if, if, if you're happy there's conventional anatomy and there's bleeding, then this again, like I said, will suggest an IVC or HEPATIC may bleed. Um, if this is the case that has a very high mortality over 50%. Um, and there's no real consensus on the optimal management of these. Um, possible options would be immobilize the liver and pack around the cava in hepatic vein and transfer them to the HPV center. That's probably the safest, er, and least risky thing to do. What a HPV surgeon might do would be, um, uh, they might do a total vascular occlusion. So, put a pringle on supra and intrahepatic, er, er, clamping. Um, er, and, and that obviously stop, uh, reduces the venous return. Um So they may also do a venovenous bypass the left femoral vein to er internal jugular to maintain the venous return. And so with the patient, uh the liver vascularly occluded and on patient on bypass, then you can try and do a direct venous repair. Um or uh a a patient may need a low bar resection. Uh if a a major passing pain's been been injured, um role of transplant. Um So there are few studies which have looked at the role of transplant, liver trauma. So there's a study where there, there were eight, a patient of a study of eight patients with major liver trauma who needed total hepatectomies just because of uncontrolled bleeding and necrosis. Um the donor as you can imagine wasn't immediately available. Um So during the anhepatic phase, the the the surgeons put the patient on a Porto cable shunt as a sort of bridge. Um this had this the 75% mortality. Um So this is an extremely rare situation to be in and is really used in exceptional circumstances. Um So this gives a, a quite a good summary. So this is from the World Society of Emergency Surgery. It gives quite a good summary of management of liver trauma. So essentially it, if the patient is unstable when they come in, like any trauma, they go to the theater. If they're an extremist, you can consider an emergency room, thoracotomy and cross clamp the descending aorta or use things like Robbo, which I've, I've never seen um, er, if they're stable, get an appropriate CT scan and assume there's no other indication for the theater. Um You can maybe manage these conservatively, er, if there's a blush, get an angio embolize. If there's no blush, then manage them conservatively embolization fails, then into theater or if at any point the non operative management fails, er, then you need to consider it, er, taking the patient to theater um, complications of liver trauma. So 20% of patients will develop some sort of bile leak. Um This can either be bile sloshing around freely in the peritoneal cavity and the patient will develop per biliary peritonitis. In this case, uh, the patient will need a, a wash out and a drain and then an E RCP and a short stent placed across uh the ampulla. And the reason for that, as I'm sure, you know, is to disrupt the high pressure sphincter. So then bile preferentially flows down the bile duct rather than out through the injured biliary radical. Um So it, it, it, it, then it then er, slows down the bile leak. Um er, the other way a bile leak can present is rather than Frank peritonitis is a localized collection or a biloma which then requires a percutaneous drain. And if, if, if drainage is ongoing and doesn't slow down, then again, the patient will need the RCP and stent hematomas can get infected that need draining. Um Pseudoaneurysms occur in about 5% of trauma patients. Uh These can either be of the main hepatic artery or even intrahepatic and this requires embolization before they bleed. Um hemobilia, um er it's fairly rare but can occur if the patient starts developing jaundice or features of an upper gi bleed. And then, then in that situation, you need to do a CT angio to see if there's still any active bleeding and embolize if appropriate and also have her do an E RCP and stent. Um cos it's likely that blood within the bile duct is clotted off and causing a hold up in the, in the biliary system. Um liver uh abscesses can form um either uh u usually because of an evolving ischemia. Uh and these require percutaneous drainage and usually long term antibiotics for a good 6 to 8 weeks. Um If part of the liver becomes ischemic, uh your options are, if it's not a major lobe, you can just leave it and let it atrophy. Um But if it's a major, a big volume of liver, uh the patient may need a delayed liver resection. Um Follow up there, don't, we don't routinely do any follow up scans as outpatients for, for trauma patients unless as needed. Um Or if we know they've got a complication that we want to follow up, like we're monitoring a collection or a blo or something. Um Most injuries will heal by four months and patients can be back to normal at that time point as well. Um The outcomes really depend on the severity of the injury as well as the other, any other injuries. The patient has. The overall mortality is somewhere between 10 and 15%. Uh more. So with blunt trauma than penetrating trauma, er, and early death, as you can imagine is, are usually due to uncontrolled bleeding. Whereas later deaths are the septic complications and the the the multiorgan failure that comes with that. So with liver trauma, atl S principles is always the clinical picture is more important than the grade of the injury. If they're unstable theater, if they're stable, then consider conservative management principles of damage control surgery apply important, which includes uh correcting the physiology. Um embolization is being increasingly used both in the opera as an adjunct to operating as well as in a non, non operate, operating er non operative strategy. Um always involve H PB early on um and uh do interval scans, both with arterial and portal faces to detect any complications. Um I know I've got um so I've got a few slides on bile duct and pancreatic trauma. Um maybe 1012 slides. I don't know how we're doing time wise. So um it's 10 past eight. We're a little bit over but um I'm finding it really interesting. So I'm very happy for you to carry on. People can drop off if they need to. Yeah, but, um, otherwise don't forget about, um, listing any questions for him. I, if you have any as we're going in. Um, so yeah, I've just got a, a few slides, uh, on some less common HPV traumas. So the extrahepatic bilary tract, so that's the, the, the bile duct as well as the gallbladder. So, these are quite uncommon. Um, they usually occur due to penetrating rather than blunt trauma and they rarely occur in isolation. Most of these patients will have a coexisting liver injury or a, an injury to a surrounding organ. Um, they're often recognized on CT or just found incidentally during a trauma laparotomy. Um, the, the most frequently all get injured part is the gallbladder. Um, now the types of gallbladder injury can either be a contusion, uh, which just resolves on its own, but you have to be just be a bit wary because you can get hematomas in the wall of the gallbladder which can lead to necrosis, uh, and then a delayed perforation. Um, er, rarely, the gallbladder can evolve completely off the liver and even off the gall, uh, the bile duct. Um, er, but perforation is by far the commonest, uh, commonest type of gallbladder injury. In terms of the bile duct, it can either be partially or completely transected. And the commonest sites are the, the sites where the bile duct is most fixed. So that's where the bile duct enters the pancreas or where the confluence of the bile duct exits the liver. Um in terms of how they present, as I said, they often recognize at the time of a trauma laparotomy, you often see bile staining. So obviously, you check the liver to make sure it's not coming from a liver injury. But if, if there's no liver injury, then you, you want to dissect out the hepatoduodenal ligament and see if there's any bile duct injury there. If you can't see anything, you can do an intraoptic cholangiogram using a fine needle into the gallbladder or the bile duct. Um to identify any leakage of bile patient may present with hemobilia again, blood clots within the bile duct causing, causing an obstructive jaundice. Um If there's free flow of bile and high volume, then patient will get peritonitis and sepsis. Uh and often these patients will present later with problems like cholangitis because they developed ischemic strictures. So that's something to be aware of down the line. Um So management can be non operative operative like anything. So non operative really would be reserve reserved for the, the, the low volume pa partial transection of the bile duct in a very stable patient. In this situation, you would, er, insert a drain to keep the bile leak drained and then, um, proceed to an E RCP and stent, um, to help slow the, the leak down. Um, er, operative management for the, if it's a gallbladder perforation, they have a cholecystectomy. Um, and, er, if it's, er, if it's a bile duct, it's, especially if it's completely transected, um, that would be a reason to take them. You can repair bile ducts over at tube. Um, but if there's been a, an associated injury or contusion of the, the hepatic artery, then they are at risk of getting ischemic strictures. Um, uh, even with at tube in. So, uh, really the go to procedure would be a Hepaticojejunostomy. Uh, and then the last bit is just a couple of slides on pancreatic trauma. So, again, this is quite uncommon, er, the pancreas is usually injured through a direct blow or deceleration injury. So, very typical would be a handlebar injury. Um, the neck of the pancreas is the most commonly injured part because it, it crosses the spine so it gets crushed across a, against the spine and because the pancreas is retroperitoneal, er, quite a large force is needed to injure it. So, if you have got a pancreatic injury, just be aware of other injuries, the diagnosis essentially is um er similar to that of pancreatitis. So you'd see raised uh pancreatic enzymes. So, lipase would be up, er, amylase would be up lipase as you know, is more sensitive than amylase on the CT, which again would be an arterial and portal venous phase. Um you'd see fluid in the lesser sac and retroperitoneum, uh inflammation of the pancreas and some fat stranding around. So, it features of pancreatitis essentially uh on paper. Um Usually the thing we're most interested in in pancreatic injuries is the integrity of the main pancreatic duct cos that dictates how we're gonna manage the patient. Often the C TCAT scan will tell you that the trauma CT can tell you that. But if there's any doubt and the patient's stable, um you should do A M RCP with contrast and that will tell you with a bit more sensitivity than a CT scan, uh whether the main pancreatic duct is intact, but often the CT scan will tell you, give you the information you need and you don't need to do an M RCP. Uh Pancreatic trauma is again, classified using the American system. So one is a contusion uh of the paralia but no involvement of the duct. Two is a slightly bigger contusion. Again, no involvement of the duct three is where you have a laceration uh in the distal pancreas. So that's left of the SMV. Um and it, and it involves the main pancreatic duct four is where, again, the main duct is involved, but it's to the right of the SMV. Um So it's a proximal proximal injury and five is complete destruction of the head of the pancreas. Um This is a, a general scheme of how you would manage them. So, again, an unstable patient as with any trauma goes to theater. Um if they're stable, has a CT scan, if there's a bit of contusion, a bit of fluid, you manage them conservatively. But if the CT suggests a major duct injury, then they go to theater. If there's any doubt M RCP, with contrast to assess the main pancreatic duct, uh and then manage that accordingly. Um So what you actually do in theater depends on what type of injury you find, cos often the CT scan will under call or over call an injury. Um So you want to, when you do usual trauma, laparotomy uh to access to the pancreas, you open the lesser sacs of the gastrocolic ligament. Um and you Concor the duodenum. Um So for grade one and two injuries, you simply, you leave a drain and you start them on a somatostatin analog. Um and uh and, and leave it as that um with, with a laceration that's, and the distal pancreas are left of the S MV that requires a distal pancreatectomy. And if you can, you should try and preserve the spleen as well because it's not a, it's not a cancer operation. Um If it's a grade four, then you can either leave a drain uh and come out or you can do a, a put up a root loop and do a pancreaticojejunostomy. So drain the pancreatic duct into the jejunum. Um And then five, which is complete destruction of the head, you'd consider doing a staged whipple. So in the initial operation, you do the resection, part of the Whipples. Um So duodenum head of pancreas bile duct um and that comes out staple the ends of tie off the, the bile duct, send the patient to itu for 24 48 hours, get them stabilized, optimized and then bring them back for the reconstruction uh of the gastro, the HEP G and the Pancreaticojejunostomy. Um If uh if there's any, if you think that the patient can't go undergo a second operation, cos they're too unwell. Um or they may not tolerate a leak from a pancreaticojejunostomy, which is the main thing we worry about in the Whipples. Um Then you can do a total pancreatectomy at the time of the first operation. Um But that's a call you'd make at the time. Um And some of the complications you see after pancreatic trauma, the commonest by far is pancreatitis and often that is a necrotizing pancreatitis. Um pseudocyst formation, especially if the main pancreatic duct is disrupted. Um peripancreatic collections and a pancreatic fistula, a whistle stop tour. Mhm That was great. Well, thank you. Um I had a question about the um uh the gallbladder and the gallbladder contusion that you mentioned. So, if you saw interruptively a gallbladder contusion, you're mentioning the risk of um developing necrosis later on, would you just go ahead and do a cholecystectomy? Then I think, I think, yeah, I think if it was a trauma situation with a contusion, I would. Ok. Ok. Um And it was really interesting you mentioned um about the um prophylactic low molecular weight heparin because I know definitely where I, where I'm training, we routinely are holding that for trauma patients. Right. Just again, it's just kind of, yeah, and we did a poll and all the answers we've got have said we occasionally do it, we often do it and the majority of people have said we, it's either that often or very often we're holding holding that, which is interesting. So, um that's something I definitely. No, no, absolutely. And I think you, do you remember in my practice if you speak to any trauma surgeon about any type of trauma, they will always say give prophylactic D mm mm. Um I don't know if anyone else wanted to raise any questions with them heel. Otherwise I think we'll start rounding things off. No, it doesn't look like anyone does. Um uh He also, so thank you so much for the talk and to m as well. It was a brilliant um journal club this evening. Um And we'll be in touch uh with all of you about the next journal club. Um and yeah, perfect. Thank you very much. Thank you, everyone, everyone have a great evening. Bye bye.