Background and objective The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary. Methods A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained. Results The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images. Conclusions This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption.

/pdf/classification-of-acute-pancreatitis-2012-revision-of-the-608d2rjeud.pdf

Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus

Bevacizumab plus Irinotecan,Fluorouracil,and Leucovorin for Metastatic Colorectal Cancer

ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Artificial neural networks (ANNs) constitute a class of flexible nonlinear models designed to mimic biological neural systems. In this entry, we introduce ANN using familiar econometric terminology and provide an overview of ANN modeling approach and its implementation methods. † Correspondence: Chung-Ming Kuan, Institute of Economics, Academia Sinica, 128 Academia Road, Sec. 2, Taipei 115, Taiwan; ckuan@econ.sinica.edu.tw. †† I would like to express my sincere gratitude to the editor, Professor Steven Durlauf, for his patience and constructive comments on early drafts of this entry. I also thank Shih-Hsun Hsu and Yu-Lieh Huang for very helpful suggestions. The remaining errors are all mine.

Artificial neural networks

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

/pdf/guidelines-for-perioperative-care-in-elective-colonic-1wl593eui2.pdf

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Identification of severe acute pancreatitis using an artificial neural network.

Background: Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population. Methods : Analysis of a prospectively collected database, which has been maintained in our unit since 1988. Results : Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality. Conclusion : Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy.

Background:
The aim of this study was to audit the management of patients with acute pancreatitis against the standards of practice in the British Society of Gastroenterology guidelines.

Methods:
The study assessed consecutive patients with acute pancreatitis over 5 years. Audit targets were overall mortality below 10 per cent, mortality for severe acute pancreatitis below 30 per cent, correct diagnosis and severity stratification within 48 h, aetiology determined in more than 80 per cent, availability of computed tomography and high-dependency or intensive therapy units when indicated and definitive treatment of gallstone pancreatitis within 2 weeks.

Results:
Of 759 patients with acute pancreatitis, 219 (28·9 per cent) had severe acute pancreatitis (SAP). Overall mortality was 5·9 per cent, and 19·6 per cent in those with SAP. Acute pancreatitis was diagnosed within 48 h of presentation in 96·3 per cent of patients. The definitive aetiology was classified in 87·5 per cent. Of patients with SAP, 95·9 per cent underwent computed tomography within 6–10 days of admission. Of 93 patients with severe gallstone pancreatitis, 48 per cent had urgent endoscopic retrograde cholangiopancreatography, and 89·6 per cent of 359 patients with acute gallstone pancreatitis underwent definitive management within 2 weeks of admission.

Conclusion:
Patients with acute pancreatitis can be managed according to revised guidelines with a low associated mortality. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

An audit of the management of patients with acute pancreatitis against national standards of practice.

Background:

Acute pancreatitis has a variable natural history and in a proportion of patients is associated with severe complications and a significant risk of death The various tools available for risk assessment in acute pancreatitis are reviewed



Methods:

Relevant medical literature from PubMed, Ovid, Embase, Web of Science and The Cochrane Library websites to May 2008 was reviewed



Results and conclusion:

Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis in the first 48–72 h Biochemical and immunological markers, imaging modalities and novel predictive models may help identify patients at high risk of complications or death Recently, there has been a recognition of the importance of the systemic inflammatory response syndrome and organ dysfunction Copyright © 2009 British Journal of Surgery Society Ltd Published by John Wiley & Sons, Ltd

https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.6431

Risk assessment in acute pancreatitis

Background The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality. Methods This was an observational study of all surgical patients in Scotland during 2005–7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders. Results There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group ( n =510 979) and in 3636 (6.4%) in the high-risk group ( n =56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01–2.84; P vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37–1.96; P Conclusions Indirect ICU admission was associated with increased mortality and increased requirement for organ support. Trial registration. UKCRN registry no. 15761.

Rowan W. Parks

Papers

Identification of severe acute pancreatitis using an artificial neural network.

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy.

An audit of the management of patients with acute pancreatitis against national standards of practice.

Risk assessment in acute pancreatitis

Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study