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Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.

The type of inguinal hernia repair used depends on many factors but predominantly the surgeon’s training, interpretation of the literature, and personal preference. This prospective cohort study describes a consecutive series of open mesh inguinal hernia repairs (modified Lichtenstein technique) performed as an outpatient procedure using 2 different mesh types. Analysis was undertaken on 540 consecutive patients who underwent inguinal hernia repair between January 2007 and December 2012. Short-term outcomes were compared between those repaired with conventional polypropylene mesh and those with Parietex ProGrip mesh. Most patients were male (89%) and the mean age was 63 years. The median operative time was 50 minutes for unilateral hernias and 90 minutes for bilateral hernias. The use of Parietex ProGrip mesh reduced the operative time to 40 minutes for unilateral hernias (P < .01) and 75 minutes for bilateral hernias (P < .01). After unilateral hernia repair, 88% of the patients were discharged home within 4 hours of operation. There was no mortality and the overall complication rate was 7.4%. One patient developed a pulmonary embolus but the remainder of the complications were minor. Twenty-four hours postoperatively, 74% of the patients were either totally pain free or had minimal discomfort. At 4 weeks, 97% of the patients were either pain free or had minimal discomfort. Patients who underwent unilateral inguinal hernia repair with Parietex ProGrip mesh had the most rapid return to normal activities (10 vs 14 days, P < .04). Open anterior inlay mesh repair is safe and results in minimal postoperative pain and early return to normal activities. ProGrip mesh resulted in a shorter operative time and more rapid return to normal activities compared with polypropylene mesh (10 vs 14 days). •ProGrip mesh for open inguinal hernia repair allows shorter operative time and rapid return to normal activities compared with polypropylene mesh (10 vs 14 days).

Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes. Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA−; n = 65) IPDA ligation groups. Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA−, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA−, 76% vs 65%; P = .426) or overall (P = .82) survival. Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.

OBJECTIVE:: To investigate the factors regulating the increase in adipose tissue blood flow following meals. DESIGN:: Eight subjects were fed three isoenergetic meals; two high-fat meals rich in either saturated or polyunsaturated fatty acids and one low-fat, high-carbohydrate meal. MEASUREMENTS:: Blood samples were taken and adipose tissue blood flow was measured before and for 6 h after the meal. Plasma glucose, insulin, non-esterified fatty acid, total and chylomicron-triacylglycerol and catecholamine concentrations were measured. RESULTS:: Adipose tissue blood flow rose to a peak after all three meals (P<0.05 for each). The three meals stimulated adipose tissue blood flow at similar times. There was a marked and statistically significant similarity in the time course of changes in blood flow and insulin concentrations. In contrast, noradrenaline concentrations peaked later than adipose tissue blood flow (P=0.014). CONCLUSION:: Adipose tissue blood flow may be 'carbohydrate-stimulated' rather than 'fat-stimulated', with insulin having a vasodilatory role in adipose tissue as in skeletal muscle. INTERNATIONAL JOURNAL OF OBESITY: (2001) 25, 1294-1299

OBJECTIVE: To test the hypothesis that intravenous infusion of lipid would bring about changes in adipose tissue metabolism, which would tend to spare net fat mobilization, and to attempt to identify the mediators of such responses. DESIGN: The triacylglycerol (TG) emulsion. Intralipid, was infused and metablic changes in subcutaneous adipose tissue and forearm muscle were assessed by measurements of arterio-venous differences. SUBJECTS: Six normal male subjects aged 21-37 y, with body mass index (BMI) 23.0-25.9 kg/m2. RESULTS. Plasma TG and non-esterified fatty acid (NEFA) concentrations rose during infusion as expected. The rise in systemic plasma NEFA concentration occurred despite decreased NEFA release from adipose tissue. Intralipid infusion resulted in a suppression of intracellular lipolysis in adipose tissue, by mechanisms which are not clear. Plasma leptin concentrations, measured in a search for the regulator of lipolysis, showed consistent leptin release from adipose tissue which did not change significantly with time. CONCLUSION: The suppression of intracellular lipolysis in adipose tissue during Intralipid infusion is a new observation and may reflect a novel mechanism for regulation of fat storage.

Bouldery riverbed lands occupy about one-third of the geographical area in Doon Valley of north-west India. These marginal lands need rehabilitation through establishment of silvopasture system for meeting the biomass requirements of resource-poor farmers. A study was carried out for 14 years (1980 to 1993) at Dehradun, involving four multi-purpose tree species viz. Albizia lebbek (L.) Benth., Grewia optiva Drumm., Bauhinia purpurea L. and Leucaena leucocephala (Lamk.) de Wit.; and two grass species viz. Chrysopogon fulvus (Spreng.) Chiov. and Eulaliopsis binata (Retz.) C.E. Hubb. Fifty and 75% of the tree crown was lopped once a year after four years of age. Tree survival decreased with age, and was highest with L. leucocephala (86.9% in 1993 of initial density of 625 trees ha^sup -1^) and lowest with B. purpurea (49.3%). Canopy parameters of trees progressed differently, presumably due to their varying growth habits. The trees of A. lebbek were taller with more crown spread, whereas G. optiva had more crown height with lesser crown spread. Stem diameter growth of A. lebbek was highest followed by B. purpurea. Lopping intensity did not affect tree survival and also canopy growth in most years, but collar diameter and diameter at breast height (dbh) decreased significantly at the higher intensity of lopping. Intercropped grass species E. binata caused a greater adverse effect on the tree survival and growth parameters than C. fulvus. The biomass production (leaf and branch wood weight of lopped material) was highest at eight years of age in 1987 but showed no definite trend over the study period. Bauhinia purpurea produced the highest biomass and L. leucocephala the lowest, despite opposite trends in their survival. The performance of A. lebbek was on par with B. purpurea in the later years (1990--1993), but G. optiva was inferior despite its superiority in the early years (1984--1985). The effects of lopping intensity were not appreciable, but intercropping with E. binata decreased leaf and branch wood production significantly compared with C. fulvus throughout. However, the adverse effect was comparatively less pronounced on B. purpurea and A. lebbek than on G. optiva and L. leucocephala. The fibre yield of G. optiva also decreased due to intercropped E. binata compared with C. fulvus.[PUBLICATION ABSTRACT]

In a long-term study (1980 to 1993), the survival, growth performance and biomass production of two grass species viz. Chrysopogon fulvus (Spreng.) Chiov. and Eulaliopsis binata (Retz.) C.E. Hubb. were assessed when intercropped with four tree species viz. Albizia lebbek (L.) Benth., Grewia optiva Drumm., Bauhinia purpurea L. and Leucaena leucocephala (Lamk.) de Wit. on the bouldery riverbed lands of Doon Valley of north-west India. The survival of grass clumps was higher under the canopy of B. purpurea (48.3% in 1993 of the initial planting density of 20,000 clumps ha^sup -1^ in 1980) and G. optiva (47.4%) than of L. leucocephala (31.1%) and A. lebbek (29.4%), and at 75% intensity of tree lopping (40.9%) than at 50% (37.1%). The effect of tree species on different growth parameters of grasses was not uniform, with G. optiva and B. purpurea causing comparatively more synergistic effect on clump height and clump diameter respectively. Although the performance of grasses was good under A. lebbek and L. leucocephala in the early years (1980--1987), these tree species resulted in the lowest grass dry weight in the later years up to 1993. The beneficial effect of higher lopping intensity of 75% was observed on the growth and biomass production of grasses over 50% lopping, presumably due to increased light penetration into the under-storey. The biomass production of grasses reached a maximum at four years of growth in 1983, after which, it decreased gradually to less than half in 1993. Eulaliopsis binata showed higher survival, growth and biomass production than C. fulvus throughout the period of study. The total biomass production was highest in association with B. purpurea followed by G. optiva, which appeared to be the most suitable tree species along with E. binata for sustainable silvopasture development on the marginal lands of Doon Valley of north-west India.[PUBLICATION ABSTRACT]

The triacylglycerol emulsion Intralipid was infused into six normal subjects to investigate the metabolism of individual fatty acids in subcutaneous adipose tissue and forearm muscle’ by measurement of arteriovenous differences. The composition of plasma nonesterified fatty acids changed steadily after passage through adipose tissue and became similar to that of the emulsion’ reflecting hydrolysis of the Intralipid‐triacylglycerol by lipoprotein lipase’ since endogenous lipolysis (hormone‐sensitive lipase activity plus lipoprotein lipase hydrolysis of verylow density lipoprotein triacylglycerol) was decreased. There was no significant net release of total or individual fatty acids from forearm muscle although there was a tendency for the composition of the fatty acids in forearm venous plasma to change during passage through the tissue to reflect the composition of the emulsion. This may reflect hydrolysis of emulsion particles by lipoprotein lipase situated in capillaries which drain into the forearm vein. The behavior of stearic acid in the plasma nonesterified fatty acid pool was consistently aberrant’ with arterialized concentrations considerably higher than predicted from adipose tissue release’ both before and during Intralipid infusion. We conclude that there are no significant differences in the metabolism of specific fatty acids’ with the exception of stearic acid.