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Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center:Value of tailored peri-pancreatectomy protocols

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world Journal of Gastrointestinal Surgery 2024年第3期16卷 681-688页

作者： Shamir O Cawich Elijah Dixon Parul J Shukla Shailesh V Shrikhande Rahul R Deshpande Fawwaz Mohammed neil w pearce wesley Francis Shaneeta Johnson Johann Bujhawan Department of Surgery University of the West IndiesSt Augustine 000000Trinidad and Tobago Department of Surgery Faculty of MedicineUniversity of CalgaryCalgaryAlberta T2N2T9Canada Department of Surgery Weill Cornell Medical CollegeNew YorkNY 10065United States Department of Surgical Oncology Tata Memorial CenterHomi Bhabha National UniversityMumbai 400012India Department of Surgery Manchester Royal InfirmaryManchester M139WLUnited Kingdom University Surgical Unit Southampton General HospitalSouthampton SO166YDUnited Kingdom Department of Surgery University of the West IndiesNassau N-1184Bahamas Department of Surgery Morehouse School of MedicineAtlantaGA 30310United States Department of Surgery General Hospital in Port of SpainPort of Spain 000000Trinidad and Tobago

BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for *** ability to rescue patients from post-PD complications is as a recognized quality *** protocols were instituted at our low volume facility in the year *** To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of *** A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,***-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD *** Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this *** complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their ***(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring *** low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major *** attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protoc

关键词： Pancreas Complication Rescue Failure Morbidity Mortality Pancreaticoduodenectomy

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whipple’s operation with a modified centralization concept:A model in low-volume Caribbean centers

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world Journal of Clinical Cases 2022年第22期10卷 7620-7630页

作者： Shamir O Cawich neil w pearce Vijay Naraynsingh Parul Shukla Rahul R Deshpande Department of Clinical Surgical Sciences University of the West IndiesSt Augustine 000000Trinidad and Tobago University Surgical Unit Southampton General HospitalSouthampton SO166YDUnited Kingdom Department of Surgery Weill Cornell Medical CollegeNew YorkNY 10065United States Department of Surgery Manchester Royal InfirmaryManchester M139WLUnited Kingdom

Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume ***,this is not practical in small,resource-poor countries in the *** these settings,patients have no option but to have their PDs performed locally at low volumes,occasionally by general *** this paper,we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income ***,we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries,such as those in the *** paper has two ***,we performed a literature review evaluating studies published on outcomes after PD in high volume *** data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization *** the authors’opinions,most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed *** these settings,their only options are to have their operations in the resource-poor,low-volume settings in the ***,post-operative outcomes may be improved,despite low-volumes,if a modified centralization concept is encouraged.

关键词： Pancreas Surgery Pancreatectomy whipple’s Pancreaticoduodenectomy

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Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

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world Journal of Gastrointestinal Surgery 2021年第10期13卷 1122-1135页

作者： Shamir O Cawich Michael D Kluger wesley Francis Rahul R Deshpande Fawwaz Mohammed Kimon O Bonadie Dexter A Thomas neil w pearce Beth A Schrope Clinical Surgical Sciences University of the West IndiesTunapuna 331333Trinidad and Tobago Department of Surgery New York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY 10032United States Department of Surgery University of the West IndiesNassau N-1184Bahamas Department of Surgery Manchester Royal InfirmaryManchester M139WLUnited Kingdom Department of Clinical Surgical Sciences University of the West IndiesTunapuna 331333Trinidad and Tobago Department of Surgery Health Service AuthorityGeorgetown 915 GTCayman Islands Department of Surgery Southampton General HospitalSouthampton SO166YDUnited Kingdom Department of Surgery Columbia University College of Physicians and SurgeonsNew YorkNY 10032United States

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections *** concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich ***,this is not the environment that many surgeons in developing countries work *** patients often do not have the opportunity to travel to high volume centres for ***,we sought to review the existing data on MIS for the pancreas and to *** this paper,we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries,such as those in the *** paper has two ***,we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the *** data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital *** pancreatic case volume in the Caribbean,and financial barriers to MIS in general,laparoscopic distal pancreatectomy,enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare *** is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

关键词： Pancreas Surgery Laparoscopic Minimally invasive Pancreatectomy whipple’s Pancreaticoduidenectomy

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whipple’s pancreaticoduodenectomy at a resource-poor,low-volume center in Trinidad and Tobago

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world Journal of Clinical Oncology 2022年第9期13卷 738-747页

作者： Shamir O Cawich Dexter A Thomas neil w pearce Vijay Naraynsingh Department of Surgery Port of Spain General HospitalPort of Spain 000000Trinidad and Tobago Department of Surgery Southampton General Hospital National Health Services TrustSouthampton SO166YDUnited Kingdom

BACKGROUND Many authorities advocate for whipple’s procedures to be performed in highvolume centers,but many patients in poor developing nations cannot access these *** sought to determine whether clinical outcomes were acceptable when whipple’s procedures were performed in a low-volume,resource-poor setting in the west *** To study outcomes of whipple’s procedures in a pancreatic unit in the west Indies over an eight-year period from June 1,2013 to June 30,*** This was a retrospective study of all patients undergoing whipple’s procedures in a pancreatic unit in the west Indies over an eight-year period from June 1,2013 to June 30,*** This center performed an average of 11.25 procedures per *** were 72 patients in the final study population at a mean age of 60.2 years,with 52.7%having American Society of Anesthesiologists scores≥III and 54.1%with Eastern Cooperative Oncology Group scores≥*** whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in *** vein resection/reconstruction was performed in 19(26.4%)*** patients undergoing open procedures there was 367±54.1 min mean operating time,1394±656.8 mL mean blood loss,5.24±7.22 d mean intensive care unit stay and 15.1±9.53 d ***(8.3%)patients experienced minor morbidity,10(14%)major morbidity and there were 4(5.5%)*** This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring whipple’s *** volume centers in resource poor nations can achieve good short-term *** is largely due to the process of continuous,adaptive learning by the entire hospital.

关键词： Pancreas Surgery Pancreatectomy whipple’s Pancreaticoduodenectomy

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Surgical relevance of anatomic variations of the right hepatic vein

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world Journal of Transplantation 2021年第6期11卷 231-243页

作者： Shamir O Cawich Vijay Naraynsingh neil w pearce Rahul R Deshpande Robbie Rampersad Michael T Gardner Fawwaz Mohammed Roma Dindial Tanzilah Afzal Barrow Department of Surgery University of the West IndiesSt Augustine 000000Trinidad and Tobago Department of Surgery Port of Spain General HospitalPort of Spain 000000Trinidad and Tobago University Surgical Unit Southampton General HospitalSouthampton SO166YDUnited Kingdom Department of Surgery Manchester Royal InfirmaryManchester M139WLUnited Kingdom Department of Radiology University of the West IndiesSt.Augustine 000000Trinidad and Tobago Department of Radiology Port of Spain General HospitalPort of Spain 000000Trinidad and Tobago Section of Anatomy Basic Medical SciencesUniversity of the West IndiesKingston 000000Jamaica Department of Radiology University of the West IndiesSt Augustine 000000Trinidad and Tobago

BACKGROUND Variations in the anatomy of hepatic veins are of interest to transplant surgeons,interventional radiologists,and other medical practitioners who treat liver *** drainage patterns of the right hepatic veins(RHVs)are particularly relevant to transplantation *** The aim was to identify variations of the patterns of venous drainage from the right side of the *** the best of our knowledge,there have been no reports on RHV variations in in a Caribbean *** Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral *** outflow patterns were observed and RHV variants were described as:(1)Tributaries of the RHV;(2)Variations at the hepatocaval junction(HCJ);and(3)Accessory *** A total of 118 scans met the inclusion *** 39%of the scans found conventional anatomy of the main hepatic *** RHVs were present 49.2%and included a well-defined inferior RHV draining segment VI(45%)and a middle RHV(4%).At the HCJ,83 of the 118(70.3%)had a superior RHV that received no tributaries within 1 cm of the junction(Nakamura and Tsuzuki type I).In 35 individuals(29.7%)there was a short superior RHV with at least one variant *** to the Nakamura and Tsuzuki classification,there were 24 type II variants(20.3%),six type III variants(5.1%)and,five type IV variants(4.2%).CONCLUSION There was significant variation in RHV patterns in this population,each with important relevance to liver *** radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

关键词： Liver Variant Hepatic Vein Anomaly Venous,Drainage,Vena cava

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Anatomic variations of the intra-hepatic biliary tree in the Caribbean:A systematic review

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world Journal of Gastrointestinal Endoscopy 2021年第6期13卷 170-183页

作者： Shamir O Cawich Alexander Sinanan Rahul R Deshpande Michael T Gardner neil w pearce Vijay Naraynsingh Department of Clinical Surgical Sciences University of the West IndiesSt Augustine 000000Trinidad and Tobago Department of Surgery Manchester Royal InfirmaryManchester M139WLUnited Kingdom Department of Anatomy University of the West IndiesKingston KIN7Jamaica Department of Surgery Southampton University NHS TrustSouthampton SO16DPSouthamptonUnited Kingdom

BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic *** authors have documented variations in the intra-hepatic ductal system,but to the best of our knowledge there has been no report on bile duct variations in Caribbean *** To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography(MRC)in unselected patients at a major hepatobiliary referral centre in the Eastern *** of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary *** This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern *** retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1,2017 to March 31,*** consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification.A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary *** variants in our population were compared to the global *** There were 152 MRCs evaluated in this study in 86 males and 66 *** were 109(71.7%)persons with“classic”biliary anatomy(type A1)and variants were present in 43(28.3%)*** was no statistical relationship between the presence of anatomic variants and gender or *** encountered the following variants:29(19.1%)type A2,7(4.6%)type A3,6(3.95%)type A4,0 type A5 and a single variant(quadrification)that did not fit the classification *** to the global prevalence,our population had a significantly greater occurrence of A1 anatomy(71.7%vs 62.6%;P=0.0227)and A2 trifurcations(19.1%vs 11.5%;P=0.0069),but a significantly lower incidence of A3 varian

关键词： Liver Variant Biliary Duct Intra-hepatic Aberrant Trifurcation,Bifurcation

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Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

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world Journal of Hepatology 2019年第2期11卷 199-207页

作者： Shamir O Cawich Ravi Maharaj Vijay Naraynsingh neil pearce wesley Francis Kimon O Bonadie Dexter A Thomas Department of Clinical Surgical Sciences University of the West Indies Department of Surgery University Hospital Southampton NHS Trust Department Surgery University of the West Indies Department Surgery Cayman Islands Health Service Authority

BACKGROUND Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver *** has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high *** high volume referral centers are usually located in developed countries,but many patients in developing nations are not able to access these centers because of financial limitations,lack of social support and/or travel ***,local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver *** is the situation in many Caribbean *** To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the *** we prospectively studied all patients who underwent major liver resections over five *** following data were extracted:patient demographics,diagnoses,ECOG status,operation performed,post-operative morbidity and *** analyses were performed using SPSS ver 16.0 RESULTSThere were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/***-nine major hepatic resections were performed for:colorectal liver metastases 40(58%),non-colorectal metastases 9(13%),hepatocellular carcinoma 8(11.6%),ruptured adenomas 4(5.8%),hilar cholangiocarcinomas 4(5.8%),hemangiomata 2(2.9%),trauma 1(1.5%) and hepatoblastoma 1(1.5%).Twenty-one patients had at least one complication,for an overall morbidity rate of 30.4%.There were minor complications in 17(24.6%)patients,major complications in 11(15.9%) patients and 4(5.8%) *** There are unique geographic,political and financial limitations to healthcare delivery in the ***,clinical outcomes are acceptable in the established,low-volume hepatobiliary centers in the Eastern Caribbean.

关键词： Liver Surgery Resection Caribbean Volume Outcomes

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IARC专著:人体致癌危害评估40年

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环境与职业医学 2016年第2期33卷 202-207页

作者： neil pearce Aaron Blair Paolo Vineis 汪源金泰廙 Agency is unknown

[背景]最近,国际癌症研究机构(IARC)人体致癌风险评估项目因其评估结果和所采用的评估方法而备受批评。一些评论人士认为,IARC工作小组未能认识到工作小组成员的研究弱点和偏倚,从而导致了对一些人体致癌性物质的不恰当分类。[目标]本... 详细信息

[背景]最近,国际癌症研究机构(IARC)人体致癌风险评估项目因其评估结果和所采用的评估方法而备受批评。一些评论人士认为,IARC工作小组未能认识到工作小组成员的研究弱点和偏倚,从而导致了对一些人体致癌性物质的不恰当分类。[目标]本述评的作者均为人体致癌物识别和危害评估相关学科的科学家。我们仔细检查对于IARC分类过程的评论,确定这些问题的合理性。本文呈现检查结果,回顾IARC评估历史,并描述IARC评估过程。[讨论]我们认为最近的这些批评不足为信。IARC汇集不同学科背景的科学家加入工作小组的程序以及进行文献回顾和各种物质危害评估的方法,提供了恰如其分的评估并合理说明了证据的权重。个别科学家对某些评估的不同意见并不能证明过程存在问题。长久以来评审过程经过了不断的修改,且将在今后继续进行修改,从而得以完善。从理论上而言,任何过程都能完善,我们支持对IARC过程进行持续的回顾和改善。但这并不意味着目前的程序存在错误。[结论]IARC专著已经并将继续为改善公众健康的社会性行动提供科学支持。

关键词：危害评估 IARC 评论人士评估项目评估过程致癌性流行病学研究分类过程文献回顾评审过程

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多因素影响下的流行病学研究

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中国处方药 2008年第4期7卷 69-71页

作者： neil pearce 黄艳

1988年4月8日,星期五,上午10:30,当笔者正在新西兰惠灵顿的办公室里工作时,一位不速之客来访,告诉笔者非诺特罗(fenoterol)这种药物很可能在新西兰引起哮喘死亡率的增加。2年后,在流行病学专家的努力下,新西兰严格控制使用非诺特罗,其... 详细信息

1988年4月8日,星期五,上午10:30,当笔者正在新西兰惠灵顿的办公室里工作时,一位不速之客来访,告诉笔者非诺特罗(fenoterol)这种药物很可能在新西兰引起哮喘死亡率的增加。2年后,在流行病学专家的努力下,新西兰严格控制使用非诺特罗,其所致的哮喘死亡率也下降了一半多。该药在澳大利亚、日本的使用也受限。其它国家的非诺特罗生产商也不得不建议药物剂量减半。美国食品药品监督管理局(FDA)也时刻关注着β受体激动剂的安全性,非诺特罗即属于该类的哮喘药物。一些重要的国际医学期刊上也发表了许多有关的评论,希望重新评估非诺特罗这一类药物的安全性。可以说当时那两年流行病学研究的成绩斐然,但是同时也是非常困难的两年。在这个时期,关于该药的流行病学研究是在相当大的压力下进行的,压力来自于非诺特罗的生产商、生产商聘请的流行病学专家、甚至是临床医生,因为临床医生不相信非诺特罗具有安全风险。这是一个非常尖锐的流行病学问题。这仅仅是一个例子,许多同行在进行药物流行病学研究时都曾遇到各种困难和阻力。

关键词：流行病学专家美国食品药品监督管理局 fenoterol 非诺特罗 β受体激动剂哮喘药物国际医学期刊药物流行病学

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Laparoscopic liver resection for hepatocellular adenoma

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world Journal of Gastrointestinal Surgery 2011年第7期3卷 101-105页

作者： Mohammed Abu Hilal Francesco Di Fabio Robert David wiltshire Mohammed Hamdan David M Layfield neil william pearce Hepatobiliary and Pancreatic Surgical Unit Southampton University Hospitals NHS TrustTremona RoadSouthampton SO16 6YDUnited Kingdom

AIM:To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma(HA). METHODS:we reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS:Thirteen patients underwent fifteen pure laparoscopic liver resections for HA(male/female:3/10; median age 42 years,range 22-72 years).Two patients with liver adenomatosis required two different laparoscopic operations for ruptured *** for surgery were:symptoms in 12 cases,need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one *** were related to bleeding in 10 cases,sepsis due to liver abscess following embolization of HA in one case and mass effect in one case(shoulder tip pain).Five cases with ruptured bleeding adenoma required emergency admis-sion and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively *** patients(62%)required major hepatectomy[right hepatectomy(n=5),left hepatectomy (n=3)].No conversion to open surgery *** median operative time for pure laparoscopic procedures was 270 min(range 135-360 min).The median size of the excised lesions was 85 mm(range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring *** was nil. The median hospital stay was 4 d(range 1-18 d)with a median high dependency unit stay of 1 d(range 0-7 d). CONCLUSION:The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.

关键词： Laparoscopy Minimally-invasive surgery Hepatocellular adenoma Major hepatectomy Outcome

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