Pancreatic theory of relativity...

Pancreatic duct and parenchyma has different benchmarks in nomenclature. The author discusses the proposition to unify the description system of procedures and surgeries within pancreas according to the direction of pancreatic juice natural flow.

Ureteric Stenting in Kidney Transplant Recipients, Gdansk Centre Experience, Poland.

BACKGROUND: The role of ureteric stenting in kidney transplant recipients is still debatable. Stenting can reduce the incidence of urine leaks and ureter stenosis, but can be also associated with specific complications, particularly urinary tract infections (UTIs). MATERIAL AND METHODS: To estimate the influence of ureteric stenting on urological complications in kidney transplantation (KTx), we retrospectively analyzed all KTx performed between January 2011 and December 2016 in Gdansk Transplantation Centre, a total of 628 patients. Ureteric stenting was used in 502 patients (80%)-double-J (DJ) group. Catheters were implanted during the surgical procedure and left in situ for a mean time of 30 days. RESULT: The frequency of urinary leaks was 10 times higher in patients without stenting (10%). Ureter stenosis was also more frequent in the non-DJ group (8.7% vs 1.6%, P < .05). Multiple-regression modeling showed that the urinary not stenting was a risk factor for urinary leak (adjusted odds ratio [AOR] = 0,1; 95% confidence interval [CI]: 0.03-0.26; P < .01), ureter stenosis (AOR = 0,16; 95% CI: 0.06-0.41; P < .01), and generally reoperation after KTx (AOR = 0,46; 95% CI: 0.28-0.77; P < .01). Acute rejection and delayed graft function were equal in both groups. Mean serum creatinine concentration 1 month after transplantation was similar in both groups (1.5 mg/dL in the DJ group and 1.44 mg/dL in the non-DJ group, P > .05). UTIs were more frequent in the DJ group (22.1% vs 16.7%), but the difference was not significant. Time of hospitalization was longer in patients with UTI (34 vs 22 days, P < .05). CONCLUSIONS: Ureteric stenting can protect patients from most frequent urological complications like urine leaks and ureter stenosis. The influence of ureteric stenting on UTI development is not strong in our material.

Pancreatic remnant fate.

There is eternal discussion on the best surgical method of pancreatoduodenectomy and reconstruction method. Several different methods of pancreatic stump anastomosis exist. The most popular argument taken into account in the discussion is the frequency of early postoperative complications. Relatively fewer papers analyse the late functional outcome of pancreatic surgery and the method of anastomosis employed. Authors presented short series of 12 patients after pancreatic surgery with analysis of pancreatic remnant morphology and function. Pancreatic remnant volume, pancreatic duct distension and stool elastase-1 test were analysed. There was no correlation of pancreatic exo- or endocrine insufficiency with the volume of pancreatic remnant or the kind of surgery or anastomosis performed.

[Quality assurance in colorectal cancer in Europe AD 2011]. / Qualitätssicherung beim kolorektalen Karzinom in Europa AD 2011.

INTRODUCTION: Malignant tumours are the second largest cause of death in Europe. Colorectal cancer takes second place within this group and is responsible for every eighth tumour-related death. CURRENT SITUATION: Surgical quality assurance requires a prospective observational study, any different type of study is not possible. A complete recording of all treated patients is a prerequisite for quality assurance. Currently, there are quality assurance programmes in Sweden, Norway, Denmark, Great Britain, Spain, Belgium, the Netherlands as well as the multinational study for patients from Germany, Poland and Italy. These projects deliver comprehensive information regarding the treatment of colorectal cancer. However, this information is deeply rooted in the organisation of the health-care system in the given country and is not easily transferable into international settings. Also, an interpretation of the collected data is often possible only within the given health-care system. FUTURE PERSPECTIVES: First, unified initial diagnostics is a prerequisite for quality assurance -  for the local extent and exclusion / confirmation of distant metastases. Until these criteria are unified, any comparison is limited, including a comparison of survival. Second, quality-of-life is not recorded in any of the current projects. Third, the main focus of a quality assurance project must be on therapy-dependent factors. The most sensible method of quality control remains within the connection of preoperative diagnostics (estimate of a best-case scenario), the surgical technique (the actual result) and a standardised pathological examination (evaluation of the actual result). These parameters can be recorded and compared within a quality assurance project regardless of the limitations of the national health-care systems. There is no alternative to a unified diagnostics model and unified histopathological evaluation, a complete picture of treatment quality is also not possible without systematic analysis of the quality of life.

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009.

AIM: The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery. METHOD: The study included 17,964 rectal cancer patients, operated on between 1 January 2000 and 31 December 2009, from 345 hospitals in Germany. All statistical tests were two-sided, with the χ(2) test (Pearson correlation) for patients and tumour characteristics. Fisher's exact test was used for complications and 30-day mortality. RESULTS: Of the 17,964 rectal cancer patients, 16,308 (90.8%) had an open procedure and 1656 (9.2%) were started with a laparoscopy. The 1455 patients with completed laparoscopic operations had fewer intra-operative and postoperative complications (5.4%vs 7.0%, P = 0.020, and 20.5%vs 25.8%, P < 0.001, respectively) and a lower 30-day mortality rate (1.1%vs 1.9%, P = 0.023). Of the 1656 planned laparoscopies, 201 (12.1%) were converted to open. The converted group suffered more intra-operative complications (18.9%vs 3.6% for completed laparoscopy and 7.0% for open surgery, P < 0.0001) and postoperative complications (32.3%vs 18.9% for completed laparoscopy and 25.8% for open operations, P < 0.0001). The converted group also had a higher 30-day mortality rate (2.0%vs 1.0% for completed laparoscopy and 1.9% for open surgery, P = 0.043). CONCLUSION: The more favourable patient profile provided justification for a laparoscopic procedure. For those converted to an open procedure, however, there were significantly more complications than planned open surgery patients. A move away from the standard open procedure for rectal cancer surgery and towards laparoscopy is not yet feasible.

Low-volume centre vs high-volume: the role of a quality assurance programme in colon cancer surgery.

AIM: The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume. METHOD: Data were used from an observational study to determine whether outcomes of colon cancer surgery are related to hospital volume. Hospitals were divided into three groups (low, medium and high) based on annual caseload. Cancer staging, resected lymph nodes, perioperative complications and follow up were monitored. Between 2000 and 2004, 345 hospitals entered 31,261 patients into the study: 202 hospitals (group I) were classified as low volume (<30 operations; 7760 patients; 24.8%), 111 (group II) as medium volume (30-60; 14,008 patients; 44.8%) and 32 (groups III) as high volume (>60; 9493 patients; 30.4%). RESULTS: High-volume centres treated more patients in UICC stages 0, I and IV, whereas low-volume centres treated more in stages II and III (P<0.001). There was no significant difference for intra-operative complications and anastomotic leakage. The difference in 30-day mortality between the low and high-volume groups was 0.8% (P=0.023).Local recurrence at 5 years was highest in the medium group. Overall survival was highest in the high-volume group; however, the difference was only significant between the medium and high-volume groups. For the low and high-volume groups, there was no significant difference in the 5-year overall survival rates. CONCLUSION: A definitive statement on outcome differences between low-volume and high-volume centres participating in a quality assurance programme cannot be made because of the heterogeneity of results and levels of significance. Studies on volume-outcome effects should be regarded critically.

Should we preserve the inferior mesenteric artery during sigmoid colectomy?

Ligation of the inferior mesenteric artery (IMA) during sigmoid colectomy may cause sympathetic denervation of the rectal stump. The purpose of our study was to investigate the functional results after sigmoid resection following ligation or preservation of the IMA. We prospectively analysed 44 patients (21 female and 23 male, mean age 60.6 +/- 11.79 years) with sigmoid tumour. Sigmoid colectomy with preservation of the IMA was performed in 21 patients, and ligation of the IMA with sigmoidectomy was carried out in 23 patients. Bowel function follow-up was performed by use of questionnaires: standardized functional questionnaire, constipation-specific, and incontinence scales before, 6 and 12 months after surgery. The quality of life was measured by means of the Fecal Incontinence Quality of Life (FIQL) scale. After sigmoid colectomy with division of the IMA, patients presented with a higher rate of fecal incontinence and increased stool frequency compared with patients after sigmoid resection with preservation of the IMA. Deterioration of FIQL was also observed in patients with ligated IMA. Preservation of the IMA during sigmoid colectomy in selected patients lowers the frequency of postoperative impaired anorectal function.

Does the septic shock interfere experimental acute pancreatitis in rats?

INTRODUCTION: Acute pancreatitis is a disease involving pro-inflammatory mediators. Two complex and multifactorial pathogenetic ways lead to edematous or necrotizing pancreatitis. The course of the disease is thought to be the consequence of an acute inflammatory response. AIM: The authors examined the impact of Escherichia coli LPS on the acute cerulein pancreatitis in rats. METHODS: The study was performed on rats using the ceruleine pancreatitis model. The activation status of polymorphonuclear cells, blood IL-6 concentration, oxidative stress parameters, pancreatic enzymes concentration and microscopic alterations were determined at 5th and 9th h observations. RESULTS: In acute pancreatitis and acute pancreatitis with LPS groups, the peripheral polymorphonuclear cells activity was lower than in control one. Authors noticed the same neutrophil activation in acute pancreatitis after lipopolysaccharide administration although the peripheral blood polymorphonuclear cells count was significantly higher at the 9th h observation. LPS neither changed the oxidative stress within pancreatic gland, nor amylase or serum lipase activity. LPS given to acute pancreatitis animals resulted in significant increase of serum IL-6 concentration at 5th observation turning normal after 9th h. CONCLUSIONS: Collected data supports thesis of early polymorphonuclear cells involvement in acute pancreatitis and oxidative stress evidence in pancreatic parenchyma. However, results did not reveal that administration of LPS amplified inflammatory response during the course of acute pancreatitis.

Organ microcirculatory disturbances in experimental acute pancreatitis. A role of nitric oxide.

Microcirculatory disturbances are important early pathophysiological events in various organs during acute pancreatitis (AP). The aim of the study was to investigate an influence of L-arginine (nitric oxide substrate) and N(G)-nitro-L-arginine (L-NNA, nitric oxide synthase inhibitor) on organ microcirculation in experimental acute pancreatitis induced by four consecutive intraperitoneal cerulein injections (15 microg/kg/h). The microcirculation of pancreas, liver, kidney, stomach, colon and skeletal muscle was measured by laser Doppler flowmeter. Serum interleukin 6 and hematocrit levels were analyzed. AP resulted in a significant drop of microperfusion in all examined organ. L-arginine administration (2 x 100 mg/kg) improved the microcirculation in the pancreas, liver, kidney, colon and skeletal muscle, and lowered hematocrit levels. L-NNA treatment (2 x 25 mg/kg) caused aggravation of edematous AP to the necrotizing situation, and increased IL-6 and hematocrit levels. A further reduction of blood perfusion was noted in the stomach only. It is concluded that L-arginine administration has a positive influence on organ microcirculatory disturbances accompanying experimental cerulein-induced AP. NO inhibition aggravates the course of pancreatitis.

Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study.

BACKGROUND: Endoscopic polypectomy is a standard method of treatment of gastrointestinal polyps, but is associated with substantial risk of complications. The most common is hemorrhage, the rate of which varied between 0.3%, and 6%. Various prophylactic techniques have been used to reduce this incidence. The aim of this study was to establish whether the prophylactic injection of adrenaline-saline solution reduces the risk of postpolypectomy bleeding in colonoscopic polypectomy. METHODS: Between May 2000 and June 2002, patients with colorectal polyps of size > or =1 cm were randomized to receive submucosal epinephrine injection (group A) or no injection (group B). The polypectomies were carried out using the conventional method. In group A, epinephrine (1/10,000) was injected into the stalk or base of the polyp. The patients were observed for complications. RESULTS: A total of 69 patients with 100 polyps were enrolled in this study: n = 50 in group A, and n = 50 in group B, according to randomization. There were a total of nine episodes of postpolypectomy hemorrhage, one in the epinephrine group and eight in the control group (1/50 vs 8/50, p < 0.05). The bleeding correlated with the size of the polyps and the diameter of the stalks. CONCLUSIONS: Epinephrine injection prior to colonoscopic polypectomy is effective in preventing bleeding.

[Management of postoperative pancreatic fistula resistant to octreotide therapy]. / Postepowanie z pooperacyjnymi przetokami trzustkowymi opornymi na leczenie oktreotydem.

Pancreatic fistula is a rare postoperative complication, usually occurring after pancreatic surgery. Majority of them heal spontaneously, some patients require somatostatin/octreotide treatment. The authors have presented 11 patients with postoperative pancreatic fistula, in whom octreotide therapy in dose of 0.1 mg t.i.d./10 days has been ineffective. The causes of pancreatic fistula have been as follows: necrosectomy of the infected pancreatic necrosis--5 patients, distal pancreatic resection--2 patients, insulinoma enucleation--2 patients, gastrectomy with partial pancreatectomy--2 patients. In 9 patients endoscopic stenting of the main pancreatic duct has been performed. In remained 2 patients after Roux-en-Y gastrectomy the endoscopic access to Vater papilla has been impossible and the patients have received one intramuscular injection of long acting somatostatin analogue. In 8 of 9 patients with pancreatic stenting and in two patients after gastrectomy the fistula has been closed within the period of 6-17 days. In one patient after the necrosectomy the prosthesis implacement has been ineffective. This patient has been successfully treated with two additional injections of long acting somatostatin analogue (one injection/14 days). Authors have concluded that endoscopic pancreatic stenting has been an effective method of treatment of the postoperative pancreatic fistula, resistant to octreotide therapy. In some cases, additional administration of long acting somatostatin analogue has been necessary.

Nitric oxide, heparin and procaine treatment in experimental ceruleine-induced acute pancreatitis in rats.

The aim of the study was to investigate the impact of L-arginine (nitric oxide donor), L-NNA (NO synthase inhibitor), heparin and procaine on the pancreas' microcirculation, serum interleukin 6 (IL-6) level, and microscopic alterations of the pancreatic gland in acute pancreatitis (AP) in rats. AP was induced by 4 i.p. injections of cerulein (15 micrograms/kg/h). Microcirculatory values of the pancreas were measured by means of laser Doppler flowmetry 5 h after the first cerulein injection. Remarkable morphologic changes in the pancreas, including parenchymal necrosis, an elevation of serum IL-6 activity, and significant drop of pancreatic capillary perfusion was observed in rats with NO synthase inhibition. L-arginine improved the pancreatic microcirculation but worsened the microscopic alterations within the pancreas. Heparin had a beneficial effect on the microcirculatory values, serum IL-6 activity, and morphologic changes. Procaine had no effect on the course of AP. Authors conclude that heparin, improving the pancreatic capillary blood perfusion, may be considered as a promising therapeutic agent in acute pancreatitis.

Heparin and nitric oxide treatment in experimental acute pancreatitis in rats.

The aim of this study was to investigate the impact of L-arginine (nitric oxide synthase substrate), L-NG-nitro-L-arginine (nitric oxide synthase inhibitor), and heparin on the pancreas microcirculation, serum IL-6 level and microscopic alterations of the pancreas in acute pancreatitis in rats. Acute pancreatitis was induced by 4 i.p. injections of cerulein (15mg/kg). Microcirculatory values were measured by means of laser Doppler flowmetry 5 h after the first cerulein injection. Remarkable histopathological changes in the pancreas, including parenchymal necrosis, an elevation of serum IL-6 level, and a significant drop of pancreatic capillary perfusion was observed in rats with nitric oxide synthase inhibition. L-arginine improved the pancreatic microcirculation but worsened the microscopic alterations within the pancreas. Heparin had a beneficial effect on the microcirculatory values, serum IL-6 concentration, and morphologic changes. Authors conclude that inhibition of nitric oxide synthase aggravates acute pancreatitis. L-arginine treatment improves pancreatic perfusion but potentiates morphological alterations. Heparin, improving the microcirculation and inflammatory changes within the pancreatic gland, may be considered as a promising therapeutic agent in acute pancreatitis.

Microcirculatory disturbances of the pancreas in cerulein-induced acute pancreatitis in rats with reference to L-arginine, heparin, and procaine treatment.

Local microcirculatory dysfunction within the pancreatic gland might be an important factor in the conversion of oedematous to necrotizing pancreatitis. Therapeutic agents, improving the pancreatic blood flow, might be valuable in acute pancreatitis treatment. An influence of nitric oxide, heparin and procaine treatment on microcirculatory values in acute pancreatitis (AP) in rats was investigated. Acute pancreatitis was induced by i.p. injection of cerulein in four doses of 15 microg kg-1 each at 1-h intervals. The rats with pancreatitis were divided into five groups, 12 animals each. One group remained without treatment, four groups were treated i.p. either with NO synthase inhibitor L-NNA (2x25 mg kg-1 or heparin 2x2.5 mg kg-1 or L-arginine 2x100 mg kg-1 or procaine 2x25 mg kg-1. Five control groups, ten animals each, received saline, L-NNA, heparin, L-arginine or procaine only. Five hours after the first ceruleine injection microcirculatory values within the pancreas were measured by means of laser Doppler flowmetry. Acute pancreatitis caused a significant drop of microcirculatory value to 37% of the basal value. The L-NNA administration resulted in a further insignificant reduction of the pancreatic blood flow to 34%. An improvement of microcirculation was observed in rats with pancreatitis receiving heparin (76%) and L-arginine (72%). Procaine had no effect on microcirculatory disturbances within the pancreas in rats with pancreatitis. Cn-induced acute pancreatitis (AP) causes microcirculatory deterioration within the pancreas. Heparin and nitric oxide donor, L-arginine, might be considered as therapeutic agents, improving the diminished pancreatic tissue perfusion observed in acute pancreatitis. Procaine does not improve the pancreatic blood flow in acute pancreatitis.

Does nitric oxide protect from microcirculatory disturbances in experimental acute pancreatitis in rats?

The aim of the study was to investigate the potential role of nitric oxide (NO) on the microcirculation in experimental acute pancreatitis in rats. Twenty-five rats were divided into the following groups: group A (5 rats) = control; group B (5 rats) = acute pancreatitis induced by retrograde taurocholate infusion into the pancreatobiliary duct without treatment; group C (5 rats) = acute pancreatitis treated with the NO donor L-arginine; group D (5 rats) = acute pancreatitis treated with the NO synthase inhibitor N-nitro-L-arginine (L-NNA); group E (5 rats) = without pancreatitis receiving L-NNA. The animals were observed throughout 4 h. The microcirculatory values of the pancreas, liver, colon, stomach and kidney were measured by means of laser Doppler flowmetry. Three animals of group D died after the third hour of the experiment. In rats with pancreatitis, a rapid decrease in microcirculatory values was observed. The most pronounced drop in capillary blood flow within all the organs was observed in rats treated with the NO synthase inhibitor L-NNA, L-arginine administration in rats with acute pancreatitis slightly improved the microcirculatory values, although the improvement was significant in colon perfusion only. We conclude that NO may have a beneficial influence on the capillary organ perfusion in acute pancreatitis. The administration of an NO synthase inhibitor seems to have a detrimental effect on acute pancreatitis.