Pseudoaneurysm of the cystic artery after acute necrotizing pancreatitis.

A 35-year-old woman, chronic alcoholic, was admitted for an attack of acute, necrotizing pancreatitis. Antibiotics and percutaneous drainage failed to control the septic status and the pancreatic collection. Open surgery allowed a successful necrosectomy and drainage. However, a control CT scan before removal of drains showed a 1 cm diameter pseudoaneurysm of the cystic artery, not present at previous abdominal imaging. A redo laparotomy was performed followed by cholecystectomy with en bloc resection of the pseudoaneurysm and a second look of the peripancreatic area. The patient made an uneventful recovery and was discharged on postoperative day 5. Pseudoaneurysms of the cystic artery after acute necrotizing pancreatitis are very rare. Percutaneous embolization is effective in controlling the pseudoaneurysm, but requires subsequent cholecystectomy within a short delay, due to the risk of gangrene of the gallbladder requiring a further, emergency surgical treatment. Open resection of the pseudoaneurysm en bloc with cholecystectomy appears, therefore, an appropriate treatment of this rare condition. KEY WORDS: Cystic artery, Pancreatitis, Pseudoaneurysm.

Effect of surgery on pancreatic tumor-dependent lymphocyte asset: modulation of natural killer cell frequency and cytotoxic function.

OBJECTIVES: Tumor burden and invasiveness establish a microenvironment that surgery could alter. This study shows a comprehensive analysis of size, dynamics, and function of peripheral lymphocyte subsets in pancreatic cancer patients before and at different times after duodenopancreatectomy. METHODS: Lymphocyte frequency and natural cytotoxicity were evaluated by flow cytometry and in vitro assay on peripheral blood from initial and advanced-stage pancreatic cancer patients before (BS), at day 7 (PS7), and at day 30 (PS30) after surgery. RESULTS: An increase in natural killer (NK) cells and the diminution of B-cells occurred at PS30, whereas cytotoxicity decreased at PS7. The positive correlation between NK frequency and cytotoxicity at BS and PS7 revealed an altered NK behavior. The elevation of NK cell frequency at PS30, an initial defect in CD56bright NK, and the aberrant correlation between NK frequency and cytotoxicity remained significant in advanced-stage patients, whereas the diminution of NK cytotoxicity only affected initial stage patients. CONCLUSIONS: The NK cell functional ability is altered in presurgery patients; duodenopancreatectomy is associated with short-term impairment of NK function and with a long-term NK cell augmentation and reversion of the aberrant NK behavior, which may impact on immunosurveillance against residual cancer.

[Acute abdominal complications in bone marrow transplant recipients]. / Complicanze acute addominali nei pazienti sottoposti a trapianto di midollo osseo.

Bone marrow transplant is currently the treatment of choice for a number of haematological neoplasms. High doses of antiblastic drugs, immunosuppressive agents and acute graft versus host disease before and after bone marrow transplant cause toxic damage to the liver and to the gastrointestinal tract. Related acute abdominal complications often need emergency surgical treatment with a 30-60% mortality rate. In these patients the surgical strategy is complex and hard to schematise. Ninety-one patients undergoing bone marrow transplantation showed acute abdominal symptoms requiring thorough surgical monitoring: 51 had ileocolitis, 17 pancreatitis, 9 cholangitis, 6 cholecystitis, 6 appendicitis, and 2 gastric perforation. Nine patients needed an emergency operation (2 gastroduodenal resections, 1 ileal resection, 2 right hemicolectomies, 2 total colectomies, 1 cholecystectomy and one appendectomy. The operative mortality was 22.2%. Positive blood cultures were quite frequent (63.7%). Moderate granulocytopenia was observed (neutrophils: 500 x mm3) in about 40% of cases, and severe granuloctopenia in only one patient (neutrophils: 100 x mm3) with ileotyphlitis. Moderate thrombocytopenia (PLTS < 50,000 x mm3) was observed in 43.9% of cases while in three cases (all submitted to surgical treatment) the platelet count was < 5,000 x mm3. The recent increase in bone marrow transplants has led to a progressive rise in the number of patients with acute abdominal complications. When deciding the surgical strategy in treating acute abdominal complications the surgeon must consider that surgical intervention is indicated only after unsuccessful medical treatment and that the intestinal segment involved must always be removed as far as possible; severe neutropenia, thrombocytopenia (< 10,000 x mm3) and positive blood cultures, especially for CMV, are unfavourable prognostic factors.

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis.

BACKGROUND: The elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time. METHODS: From a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores >/=19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed. RESULTS: All six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was >/= 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate. CONCLUSION: In critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.

Severe bleeding from esophageal varices resistant to endoscopic treatment in a non cirrhotic patient with portal hypertension.

A non cirrhotic patient with esophageal varices and portal vein thrombosis had recurrent variceal bleeding unsuccessfully controlled by endoscopy and esophageal transection. Emergency transhepatic portography confirmed the thrombosed right branch of the portal vein, while the left branch appeared angulated, shifted and stenotic. A stent was successfully implanted into the left branch and the collateral vessels along the epatoduodenal ligament disappeared. In patients with esophageal variceal hemorrhage and portal thrombosis if endoscopy fails, emergency esophageal transection or nonselective portocaval shunting are indicated. The rare patients with only partial portal thrombosis can be treated directly with stenting through an angioradiologic approach.