Predictive value of abdominal drain amylase for postoperative pancreatic fistula following gastric resection: A systematic review and meta-analysis.

BACKGROUND: Radical dissection of lymph nodes, accompanying gastric cancer resection, can lead to collateral damage to the pancreas and development of postoperative pancreatic fistula (POPF). METHODS: We searched the Cochrane Library, MEDLINE, Embase, and Web of Science up to April 21, 2020, to identify studies documenting the value of abdominal drain amylase level (d-AMY) on postoperative day 1 (POD1) as a predictor of POPF after gastric surgery. The quality of selected studies was assessed using the QUADAS-2 tool. The diagnostic value of d-AMY on POD1 for prediction of POPF was first assessed by calculation of pooled estimates of sensitivity, specificity, likelihood ratios (LR), and the diagnostic odds ratio (DOR). Secondly, the accuracy was further demonstrated graphically with the hierarchical summary receiver operating curve (hSROC). PROSPERO registration number: CRD42020181145. RESULTS: DOR of nine studies (cases n = 1856) observing the occurrence of POPF after measurement of d-AMY on POD1 was 18.7 (95%CI: 10.0, 34.8), and the area under hSROC was 0.88 ± 0.02. The pooled sensitivity was 0.74 (95%CI: 0.66, 0.81) and specificity 0.84 (95%CI: 0.82, 0.86). The negative LR was at the lowest point of 0.16 (95%CI: 0.07, 0.37) at the cutoff value for d-AMY of 941 IU/L, while the positive LR ranged from 4.4 (cutoff 2119 IU/L) to 6.2 (cutoff 5000 IU/L). CONCLUSION: d-AMY on POD1 can be used as an accurate and non-invasive predictor of POPF in the earliest stage of postoperative course following gastric cancer resection; value ≤ 941 IU/L warrants early drain removal and low probability of POPF (any grade).

Preoperative fecal elastase-1 (FE-1) adds value in predicting post-operative pancreatic fistula: not all soft pancreas share the same risk - A prospective analysis on 105 patients.

BACKGROUND: Scores predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) mainly use intraoperative predictors. The aim of this study is to investigate the role of pancreatic exocrine function expressed by fecal elastase (FE-1) as preoperative predictor of POPF. METHODS: Patients scheduled for PD at the Department of General and Pancreatic Surgery, University of Verona Hospital, from April 2017 to July 2018 were prospectively enrolled. FE-1 was measured in a preoperative stool sample through an ELISA test. RESULTS: The study population consisted of 105 patients. The POPF rate was 17.1%. Patients developing POPF showed high values of FE-1 (454 vs 155 mcg/g; p < 0.01), and FE-1 was an independent predictor of POPF (OR 1.008, CI 95% 1.003-1.014; p < 0.01), even considering only patients with a "soft" texture. A cut-off value of 260 mcg/g presented 100% sensitivity and 64.3% specificity (AUC 0.83) in predicting POPF. Approximately 30% of patients with a "soft" pancreatic texture presented with FE-1 < 260 mcg/g and did not develop POPF. CONCLUSION: FE-1 is a promising tool to preoperatively assess the risk of POPF after PD. Further studies with larger populations are needed to potentially incorporate FE-1 into risk scores for PD with better stratification.

Randomized controlled study of the effect of octreotide on pancreatic exocrine secretion and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Octreotide is known to decrease the rate of postoperative complication after pancreatic resection by diminishing exocrine function of the pancreas. The aim of this study was to evaluate the effect of octreotide in decreasing exocrine excretion of pancreas and preventing pancreatic fistula. MATERIALS AND METHODS: Prospective randomized trial was conducted involving 59 patients undergoing pancreaticoduodenectomy for either malignant or benign tumor, 29 patients were randomized to receive octreotide; 30 patients allotted to placebo. All pancreaticojejunal anastomosis was performed with external stent of negative-pressured drainage and the amount of pancreatic juice through the external stent was measured until postoperative 7th day. Pancreatic fistula was recorded. RESULTS: There were no differences in demographics, pancreatic texture and pancreatic duct diameter between the octreotide and placebo group. The median output of pancreatic juice was not significantly different between both groups during 7 days after surgery. When the patients were stratified according to the diameter of pancreatic duct (duct ≤5 mm, > 5 mm), there were no significant differences in daily amount of pancreatic juice, however, when stratified according to pancreatic texture, median output of pancreatic juice was significantly lower in patients with hard pancreas compared with those with soft pancreas from 5 day to 7 day after surgery (p < 0.05). No significant differences in pancreatic fistula and postoperative complications were found between the octreotide and placebo groups. CONCLUSIONS: Prophylactic octreotide is not effective to inhibit the exocrine secretion of the remnant pancreas and does not decrease the incidence of pancreatic fistula after pancreaticoduodenectomy.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS).

BACKGROUND: The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS: An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS: The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION: The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.

The attenuation value of preoperative computed tomography as a novel predictor for pancreatic fistula after pancreaticoduodenectomy.

PURPOSE: Pancreatic fistula (PF) is the most serious complication following pancreaticoduodenectomy (PD). This study was performed to identify new clinical factors that may predict the development of PF after PD to improve perioperative management. METHODS: Seventy-five consecutive patients who underwent PD from 2012 to 2015 were evaluated. The patients' perioperative data including the computed tomography (CT) parameters were collected. The minimum, maximum, and mean CT attenuation values (HUmin, HUmax, and HUmean, respectively) were extracted from the pancreatic parenchyma (≥ 100 pixels), and the standard deviation of these values (HUSD) was determined from the slice in which the superior mesenteric and splenic veins were merged. PF was defined as grade B or C according to the International Study Group for Pancreatic Fistula criteria. RESULTS: The PF occurrence rate (grade B or C) was 25.3% in 75 patients. A multivariate analysis identified a larger HUSD (odds ratio 3.092; 95% CI 1.018-9.394) and higher amylase concentration in drainage fluid on postoperative day 1 (odds ratio 1.0001; 95% CI 1.00001-1.00022) as significant risk factors for PF. CONCLUSIONS: The HUSD of preoperative CT attenuation values in the pancreatic parenchyma was found to be an independent predictor for PF after PD and it might therefore positively contribute to the perioperative management of PD.

Predictive value of drain amylase content for peripancreatic inflammatory fluid collections after laparoscopic (assisted) distal gastrectomy.

BACKGROUND: Laparoscopic (assisted) distal gastrectomy (LDG) with radical lymphadenectomy for gastric cancer has been widely conducted, particularly in the Far East. Peripancreatic inflammatory fluid collection (PIFC) is a serious and frequent postoperative complication after LDG for gastric cancer. The aim of this study was to evaluate the diagnostic performance of drain amylase content (D-AMY) for clinically relevant PIFC after LDG. METHODS: Two hundred and sixty-four patients who underwent LDG with prophylactic drains were enrolled. The predictive value of D-AMY on postoperative day (POD) 1 and POD 3 in the diagnosis of PIFC was evaluated. RESULTS: Twenty (7.6 %) patients experienced postoperative PIFC. Area under the curve in terms of receiver operating characteristics curve analysis of D-AMY on POD 1 was 0.801, and the optimal cutoff value for prediction of PIFC was 904 IU/l, with 98.2 % negative predictive value. Another cutoff was proposed as 4078 IU/l, with 92.2 % specificity. Multivariable analyses identified D-AMY on POD 1 ≥900 and ≥4000 IU/l as independent diagnostic factors for PIFC. Among patients at high risk of PIFC (D-AMY on POD 1 ≥900 IU/l), those who on POD 3 retained D-AMY value in excess of 31.2 % of the D-AMY value on POD 1 were more likely to experience PIFC compared with those with a pronounced decrease in D-AMY. CONCLUSIONS: D-AMY on POD 1 serves as a predictive factor for clinically relevant PIFC after LDG. Time-dependent changes in D-AMY can also be used for determining management of drains in patients at high risk of PIFC.

A Cohort Study for Derivation and Validation of Early Detection of Pancreatic Fistula After Pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula (PF) remains the most important morbidity after pancreaticoduodenectomy (PD). Early drain removal was recently recommended. However, this is not applicable to all cases because the development of severe PF may not be obvious until a later postoperative day (POD). This study aimed to discover ways to detect clinically relevant PF early during the postoperative stage after PD. METHODS: We studied 120 patients who underwent PD. Grades B/C PF classified according to the International Study Group of Pancreatic Surgery guidelines were defined as clinically relevant PF. Logistic regression was used to identify detection factors for clinically relevant PF. Receiver operating characteristic curves were used to identify the optimal cutoff value for clinically relevant PF, and the k-fold cross-validation model to validate the cutoff value. RESULTS: Drain amylase on POD 1 and C-reactive protein (CPR) on POD 2 were independent factors for clinically relevant PF. Drain amylase >1300 IU/l on POD 1 and CRP >12.8 g/dl on POD 2 were the best cutoff values for clinically relevant PF detection and were confirmed by k-fold cross-validation. The sensitivity and specificity values were 79 and 81 %, respectively. CONCLUSIONS: Values of drain amylase and CRP combined were useful to distinguish clinically relevant PF.

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis.

BACKGROUND: Pancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula. METHODS: From January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C. RESULTS: Management of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the 'gently and softly' pancreatic manipulation, according literature, may be a risk factor. CONCLUSIONS: The authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase.

INTRODUCTION: The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF). PATIENTS AND METHODS: Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal. RESULTS: 81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP. CONCLUSION: Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.

[Possibilities of treatment of external pancreatic fistula].

Evaluation of the efficacy of sekretoliticeskoj therapy with synthetic analogue of somatostatin, a short-acting oktreotid (group 1) and extended oktreotid-depo (group 2) in 24 patients with external pancreatic fistulas after destructive pancreatitis. Results of clinical studies have shown that against the backdrop of an analogue of somatostatin-depo true healing and purulent-necrotic pancreatic external fistula occurs in less time: average 19 ± 1.8, and 16.2 ± 1.2 day observations, respectively.

Usefulness of drain amylase, serum C-reactive protein levels and body temperature to predict postoperative pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal. METHODS: From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF. RESULTS: Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m(2) to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively. CONCLUSIONS: Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.

Octreotide prophylaxis is not beneficial for biochemical activity and clinical severity of postoperative pancreatic fistula after pancreatic surgery.

BACKGROUND: Prospective randomized trials indicate that prophylactic octreotide treatment does not decrease the incidence of postoperative pancreatic fistula (POPF). The aim of this study was to analyze if octreotide prophylaxis could decrease the severity grade of POPFs after pancreatic surgery. METHOD: Seventy-eight of 684 patients undergoing pancreatic resection with POPF were included in the study. Prophylactic octreotide treatment was started immediately after surgery and was performed in 22 patients, whereas 56 patients had no octreotide treatment and served as controls. Lipase activity was measured in the abdominal drainage on postoperative days (POD) 3, 5 and 7. Primary endpoints of the study were clinical severity of the POPF and lipase activity in the drainage. RESULTS: There was no significant difference concerning length of postoperative hospital stay. Lipase activity in the abdominal drainage was not influenced by octreotide prophylaxis at POD 5 or 7 compared to POD 3. Multivariate analysis showed that the risk to develop a type B or C fistula in the octreotide group was independent of the kind of operation and the consistency of the pancreas (RR = 3.4; CI = 1.0-11.7; p = 0.050 and RR = 6.3; CI = 1.4-29.6; p = 0.019). CONCLUSION: Octreotide prophylaxis after pancreatic surgery has no beneficial effect on clinical severity of POPF.

Early intraperitoneal metabolic changes and protease activation as indicators of pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Ischaemia and local protease activation close to the pancreaticojejunal anastomosis (PJA) are potential mechanisms of postoperative pancreatic fistula (POPF) formation. To provide information on the pathophysiology of POPF, intraperitoneal microdialysis was used to monitor metabolic changes and protease activation close to the PJA after pancreaticoduodenectomy (PD). METHODS: In patients who underwent PD, intraperitoneal metabolites (glycerol, lactate, pyruvate and glucose) were measured by microdialysis, and lactate and glucose in blood were monitored, every 4 h for 5 days, starting at 12.00 hours on the day after surgery. Trypsinogen activation peptide (TAP) was measured in microdialysates as a marker of protease activation. RESULTS: Intraperitoneal glycerol levels and the ratio of lactate to pyruvate were higher after PD and glucose levels were lower in seven patients who later developed symptomatic POPF than in eight patients with other surgical complications (OSC) and 33 with no surgical complications (NSC) (all P < 0·050). TAP was detected at a concentration greater than 0·1 µg/l in six of seven patients with POPF, two of eight with OSC and two of 33 with NSC. Intraperitoneal lactate concentrations were higher than systemic levels in all patients on days 1 to 5 after surgery (P < 0·001). In patients with POPF, high intraperitoneal lactate concentrations were observed without systemic hyperlactataemia. CONCLUSION: Early in the postoperative phase, patients who later developed clinically significant POPF had higher intraperitoneal glycerol concentrations and lactate/pyruvate ratios, and lower glucose concentrations in combination with a TAP level exceeding 0·1 µg/l close to the PJA, than patients who did not develop POPF.

Effect of SMS 201-995 on exocrine pancreatic secretion in a patient with external pancreatic fistula.

The effect of SMS 201-995 on pancreatic exocrine function was studied. The SMS 201-995 was administered to a patient with an artificial external pancreatic fistula following pancreaticoduodenectomy. Variations in pancreatic exocrine function were assessed by determining the volume and components of the fistula fluid during the following periods: 5 d prior to SMS 201-995 administration, for 5 d during actual administration, and for 5 d after it had been discontinued. The SMS 201-995 was administered by subcutaneous injection of 100 micrograms every 12 h for the first 2 d and then 100 micrograms every 6 h for 3 d. This experiment demonstrated that SMS 201-995 has a strong inhibitory effect on pancreatic exocrine function, markedly reducing the amount of fistula fluid and the production of amylase, total protein, and bicarbonate.

Pancreatic excretion of dimethadione and trimethadione by repeated oral administration of trimethadione in dogs.

To examine pancreatic excretion of dimethadione (DMO), a weak organic acid, as well as of its precursor trimethadione (TMO), TMO was given orally to dogs with pancreatic fistulae at a dose of 10-160 mg/kg/day over a period of 14 days. Blood samples were taken once a day during the administration of TMO and for 7 days after discontinuation of the drug. On the 15th day, pancreatic juice was collected under stimulation by secretin (2 Crick-Haper-Raper units/kg/h). DMO concentration in plasma reached a maximal plateau around the 10th day after starting TMO administration, and depended directly on the dose of TMO. Pancreatic excretion of DMO at a steady state closely depended on both the dose of TMO and the DMO concentration in plasma. The pancreatic juice/plasma concentration ratio for DMO exceeded 1.0 at a steady rate and decreased with the increased flow rate. Pancreatic DMO clearance (DMO output/DMO concentration in plasma) increased, depending on the flow rate, the bicarbonate concentration, and pH of pancreatic juice. Pancreatic excretion of TMO was zero or extremely low.

Studies on neurotensin. II. Release of neurotensin.

The objective of these experiments was to confirm the localization of neurotensin (NT) in gut endocrine cells of the canine small intestine using immunohistochemistry. In addition, the release of NT from the canine small intestine in response to selective perfusion of a fatty acid (oleate), triglyceride (Lipomul) or products of fat digestion into various segments of the small intestine was studied. In the immunohistochemical study, NT was found to be primarily localized in true endocrine cells of the ileal mucosa. In addition, NT was not found or only negligible numbers of cells were seen outside the lower small intestine. This observation supports previous results based on radioimmunoassay and immunohistochemistry studies. Based on these morphological findings, NT would be released by luminal secretagogues, of which fat appears to be the most potent. In the selective perfusion studies, perfusion of oleic acid into the jejunum of the chronic dog caused NT release, whereas perfusion of the ileum in which NT cells were most abundant was ineffective. This observation suggests that a neural or endocrine message is released to the ileal NT cell from the jejunum, causing NT release. This series of studies was carried out to elucidate the mechanism of NT release and to find the direct luminal stimulants of NT by using both chronic and acute experimental models. These studies suggest that NT is not significantly released under anesthesia and that undigested fat, like triglyceride, does not release NT in either the upper or lower small intestine. Furthermore, digested fat, like oleate or digestive juices in the lower small intestine, is not a direct stimulant of NT release.

The penetration of antibiotics into human pancreas.

In order to analyse the penetration of two antibiotics (mezlocillin and metronidazole) which cover the spectrum of microorganisms involved in pancreatic infection, we determined their concentration in pancreatic tissue, juice and cyst fluid in 16 patients undergoing pancreatic surgery. In addition, the external pancreatic fistula fluid of one patient was analysed for antibiotic concentration and bacterial counts during a seven-day treatment with mezlocillin, metronidazole and netilmicin (i.v.). Antibiotic concentrations were determined by HPLC between 16 and 210 (median 74) min after i.v. administration of 4 g mezlocillin and 500 mg metronidazole, respectively. The median concentration of mezlocillin was 23.2 (range: 3.1-37.4) mg/kg, 15.9 (range: 4.2-55.0) mg/l and 9.9 (range: 5.2-14.8) mg/l in pancreatic tissue, juice and cyst fluid, respectively. The median concentration of metronidazole was 5.1 (range: 1.8-13.0) mg/kg, 8.5 (range: 3.6-16.2) mg/l and 1.2 (0.9-1.4) mg/l in pancreatic tissue, juice and cyst fluid, respectively. From the fistula patient, seven different bacteria were cultured (five aerobic and two anaerobic isolates); their concentration in fistula fluid ranged from 10(5) to 10(7) CFU/ml. The bacteria sensitive for mezlocillin and metronidazole disappeared after four days of i.v. treatment, whereas the two isolates sensitive for netilmicin showed continuous growth seven days after i.v. treatment. The peak concentrations for mezlocillin, metronidazole and netilmicin in the fistula fluid were 6.8 mg/l, 5.6 mg/l and less than 0.1 mg/l, respectively.