Gastrostomy as a Preemptive Measure after Pancreatoduodenectomy against Delayed Gastric Emptying: A Small Case Series and a Review of the Literature.

Delayed gastric emptying (DGE) is a common (20-30%) postoperative complication following pancreatoduodenectomy (PD) (Parmar et al., 2013). Various causes and preemptive measures have been suggested to decrease the occurrence of DGE. We added a simple step in the procedure of 26 consecutive pancreatic head resections, which seems to alleviate DGE and has never been highlighted before.

Peritoneal dialysis without a physical peritoneal dialysis unit.

UNLABELLED: Under certain circumstances when patients need peritoneal dialysis (PD) but no physical unit or official staff are available, one has to improvise ways to serve such patients. In this study we describe our experience with such patients without a physical peritoneal dialysis unit. PATIENTS AND METHODS: Since 1997 we trained 33 patients, mean age 61.7 +/- 12.8 years old. Catheter implantation was done in another hospital on them as out-patients. We used trained nurses made available by the company that supplies the PD solution. After 2004 the whole training was done at patients' home, after having been accepted by the patients. RESULTS: Catheter implantation was successful in all 33 patients. Catheter was removed from 2 patients (one and 4 years after implantation) because of relapsing peritonitis in the first and fungal infection in the second. The overall peritonitis rate was 0.18 episodes/patient year or one episode every 63.5 patient months. Actuarial patient survival was 90%, at one year, 83% at second year and 55% at third year. First and second year technique survival were 96%, and 90% respectively. CONCLUSION: Our results, should encourage those who want to provide peritoneal dialysis to their patients even when a physical peritoneal dialysis unit is not available.

Sclerosing encapsulating peritonitis secondary to CAPD: the effect of fibrotic debridement on further dialysis.

BACKGROUND: Sclerosing peritonitis (SCP) is a complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis of the peritoneum. Entrapment of the intestine in a fibrous sac resulting in complete intestinal obstruction is called sclerosing-encapsulating peritonitis (SEP) and represents the most severe form of the disease. Various reports have been pessimistic regarding the surgical outcome when SEP has caused complete intestinal obstruction. Continuation of CAPD after laparotomy is generally considered not feasible. The aim of this article is to present our experience in the surgical management of SEP and, in particular, in the postoperative continuation of CAPD. MATERIAL AND METHODS: Seventeen consecutive patients with SCP among 175 patients undergoing CAPD during a period of 14 years in a single Unit were retrospectively reviewed. Two groups of patients were recognized. The SCP group included 9 patients with incomplete intestinal obstruction that were treated with single peritoneal catheter removal and switching to haemodialysis. The SEP group included 8 patients with complete obstruction that necessitated laparotomy for surgical debridement of the fibrotic tissue and release of the intestinal loops. RESULTS: Switching to haemodialysis improved the majority of the group of patients. In 2 of the SEP group of patients (early in the series), where enterectomy was inevitable, performance of an intestinal anastomosis resulted in leakage with subsequent fatal outcome. Two of the SEP group of patients were transferred to haemodialysis after the laparotomy. In the remaining 4 SEP patients (50%), exposure of a significant portion of active peritoneal surface was achieved - called "neoperitonization"-and allowed effective continuation of peritoneal dialysis for an average duration of 16 months (range 1-32). CONCLUSIONS: In patients with SEP, careful release of the intestinal loops avoiding enterectomies and even inadvertent intestinal wounds is mandatory. Continuation of peritoneal dialysis after meticulous debridement and removal of the fibrotic tissue is possible and may be effective. To the best of our knowledge, there have not been previously reported cases of continuations of CAPD after laparotomy for SEP.

The leser-trelat sign in association with carcinoma of the ampulla of Vater.

A 45-yr-old woman was admitted to our hospital for surgical treatment of obstructive jaundice. She was treated by a standard pancreatoduodenectomy (Whipple procedure). The biopsy of the specimen disclosed an adenocarcinoma of the ampulla of Vater. Six months before the appearance of the obstructive jaundice, she noted a sudden onset of many seborrheic keratoses on the upper part of her trunk and upper extremities. This, to our knowledge, is the first case of Leser-Trelat sign associated with adenocarcinoma of the ampulla of Vater.

Contribution of pain to inspiratory muscle dysfunction after upper abdominal surgery: A randomized controlled trial.

Upper abdominal surgery causes respiratory muscle dysfunction. Multiple factors have been implicated in the occurrence of such dysfunction; however, the role of pain remains unclear. To elucidate the role of pain, we studied 50 patients undergoing elective upper abdominal surgery in a randomized, controlled investigation. Inspiratory and expiratory muscle function were assessed through sniff mouth pressure (Psniff) and maximal expiratory pressure (MEP), respectively. Pain during the pressure maneuvers was assessed with a visual analog scale (VAS). Measurements were made before surgery (Session 1), 24 h after surgery (Session 2), and 1 h later, after intramuscular administration of pethidine (analgesia group) or placebo (placebo group) (Session 3). To evaluate the effect of pain, we used a mixed-effects model with random intercept, having either Psniff or MEP as the dependent variable and both surgical operation and the level of pain as fixed effects. Upper abdominal surgery decreased Psniff in both the analgesia and placebo groups (from 70 +/- 15 to 42 +/- 11 cm H(2)O [p < 0.05] in the analgesia group, and from 69 +/- 15 to 42 +/- 10 cm H(2)O [p < 0.05] in the placebo group). Intramuscular pethidine caused an increase in Psniff to 56 +/- 14 cm H(2)O (p < 0.05), whereas placebo had no effect. Pain increased comparably after upper abdominal surgery in both groups (from 0.3 +/- 0.6 to 4.4 +/- 1.5) [p < 0.05] in the analgesia group and from 0.4 +/- 0.5 to 4.3 +/- 1.5 [p < 0.05] in the placebo group). Intramuscular pethidine decreased pain as measured by VAS score to 2.1 +/- 1.0 (p < 0.05) in the analgesia group, whereas placebo had no effect. Psniff had a statistically significant relationship to pain (p < 0.001). Adjusting for the occurrence of surgical operation did not affect this result. MEP showed the same tendency as Psniff, but the observed changes did not reach statistical significance. We conclude that pain contributes to inspiratory muscle dysfunction after upper abdominal surgery.

Laparoscopic resection of a large right adrenal gland cyst.

A case of a benign cyst of the right adrenal gland resected laparoscopically is presented. The approach was through the right subcostal space mobilizing the right lobe of the liver and the right colonic flexure. The procedure was of 75 min duration and was uneventful. The patient was discharged the 3rd postoperative day free of postoperative pain. The advantages and disadvantages of this new modality for the treatment of adrenal gland cysts are discussed.