[Intravenous glutamine and early nasojejunal nutrition in severe acute pancreatitis -- a prospective randomized clinical study]. / Intravénás glutamin és korai nasojejunalis táplálás együttes alkalmazása súlyos acut pancreatitisben -- prospektív randomizált kettos vak kontrollált klinikai vizsgálat.

INTRODUCTION: Severe acute pancreatitis (SAP) is still one of the great challenges in gastro-intestinal surgery. According to recent studies, intravenously administered glutamine with total parenteral nutrition may be beneficial in the prevention of infectious complications and may reduce mortality rate. However, it has not been investigated yet, whether i.v. glutamine is able to achieve the same effect with early enteral nutrition as well. OBJECTIVES: The objective of our prospective randomized double-blind study was to explore the effects of intravenously administered glutamine with early nasojejunal nutrition in severe acute pancreatitis. PATIENTS AND METHODS: Forty-five patients with severe acute pancreatitis (with a Glasgow score at least 3 and/or a CRP level above 150 mg/ml on admission) were randomized into two groups. Group Glutamine (n = 24) was given 0.5 g/kg/die glutamine intravenously, while the control group (n = 21) received normal amino acid solution in the same quantity for 7 days. Nasojejunal nutrition was introduced 48 hours after admission in case of all patients, and their management was the same in every other aspect, too. The primary end-points of the study were the rate of pancreas-specific infectious complications and organ failure, and the secondary end-points were the necessity for radiological and surgical interventions, length of hospital stay and mortality rate. RESULTS: In group Glutamine, infected acute peripancreatic fluid collections (APFC) were detected in 4 patients, 2 patients had post-necrotic pancreatic/peripancreatic fluid collections (PNPFC), 2 patients had infected pseudocysts and 2 patients had walled-off pancreatic necrosis (WOPN). Ten patients were cured by ultrasound assisted puncture or drainage successfully. No surgical intervention was necessary. In the control group, 4 patients had infected APFC, 2 patients had infected PNPFC, infected pseudocysts and infected WOPN were diagnosed in 3 cases. Radiological intervention was effective in 9 cases, but 3 patients needed surgery. Three patients died of multi-organ failure, thus the mortality rate of the control group was 14%, while the mortality rate of the Glutamine group was zero. The mean hospital stay of the Glutamine group was 10.6 days, which is significantly shorter than the mean hospital stay of the control group, which was 15.9 days (p = 0.00104). DISCUSSION: The results of the Glutamine group are better in every end-points, however, statistically significant difference was detected in one parameter only, the length of hospital stay.

Solid pseudopapillary neoplasm of the pancreas--proposed algorithms for diagnosis and surgical treatment.

PURPOSE: The incidence of solid pseudopapillary neoplasm (SPN) of the pancreas is rising. Although the evidence for proper management is accumulating, we still lack diagnostic and therapeutic guidelines. In this paper, therefore, we propose an algorithm for diagnosis and treatment of this rare type of tumor. METHODS: A literature search was carried out on "Medline" and "Pubmed" databases to identify studies investigating the clinicopathologic features, pathogenesis, diagnostic, and differential diagnostic pathways, and surgical and adjuvant treatment options. Evidence from relevant published literature was completed with data of six patients treated with SPN in our institution. RESULTS: This study included case series and retrospective reviews only, since no higher level of evidence exists in the relevant literature. The articles emphasized that preoperative diagnosis is desirable to set up a precise plan for surgical treatment. Further, an R0 organ-sparing resection for primary SPN and an en bloc resection of locally advanced SPN are advised, while resection of synchronous as well as metachronous distant metastases is strongly advocated for this rare type of pancreatic cancer. The role of adjuvant chemo- or radiotherapy still needs to be defined. Finally, a diagnostic and therapeutic algorithm is devised in this paper to aid proper management of SPN. CONCLUSION: Current recommendations for treatment of SPN of the pancreas rely mainly on case series as single institutional experiences and retrospective reviews. Although the level of evidence is relatively low, the way of management discussed above is likely to provide an excellent prognosis in typically young patients with SPN.

Successful treatment of mediastinal pancreatic pseudocyst by pancreatic head resection.

CONTEXT: A mediastinal pseudocyst is an unusual and rare complication of acute and chronic pancreatitis. CASE REPORT: The authors report the case of a 41-year-old male patient with a documented history of chronic pancreatitis who developed a pancreaticomediastinal fistula with mediastinal pseudocyst, which was successfully treated by pancreatic head resection (Frey). CONCLUSION: Though the choice of treatment is still controversial, the main goal of surgical treatment is to ensure the adequate flow of pancreatic juice from the pseudocyst and the pancreas.

[Solid pseudopapillary neoplasm of the pancreas]. / A pancreas solid pseudopapillaris tumora.

Solid pseudopapillary neoplasms (SPN) of the pancreas are rare tumours with low malignant potential, usually affecting young women. Due to its relatively low incidence, there are no international guidelines published on diagnosis or treatment. The aims of our study were to summarize our clinical experience of SPN in a Hungarian Surgical Centre and to discuss the relevant international literature. The clinical data of four patients treated between 2004 and 2007 in the Petz Aladár County Teaching Hospital (Gyôr, Hungary) were analyzed retrospectively. All patients were women with age of 17-49 years. In all cases SPN was diagnosed preoperatively on the basis of CT-findings and the diagnosis was confirmed by postoperative histology. After an organ-preserving radical resection of the tumour, all patients have remained disease free with an acceptable quality of life so far. Our data suggest that CT-scan is adequate to establish the preoperative diagnosis of SPN. Surgical resection should be carried out with the required radicality, but organ preservation is advised in order to provide a relatively good quality of life.

Synbiotic control of inflammation and infection in severe acute pancreatitis: a prospective, randomized, double blind study.

BACKGROUND/AIMS: Experimental and clinical studies demonstrated that probiotics containing lactobacilli significantly improve the outcome of acute pancreatitis. In a prospective, randomized, double-blinded study the role of "Synbiotic 2000", a new synbiotic composition with high colony forming unit (CFU) was evaluated in the treatment of severe acute pancreatitis. METHODOLOGY: Patients with severe acute pancreatitis were randomized into two groups. Nasojejunal feeding was commenced within 24 hours after admission in both groups and continued for at least seven days. The first group of patients received four different lactobacilli preparations with 1010 CFU, respectively, and prebiotics containing four bioactive fibers (inulin, beta-glucan, resistant starch and pectin) in addition. Patients in the second (control) group received only prebiotics. RESULTS: 62 patients with severe acute pancreatitis completed the study. Altogether 8 patients died. Lower incidence of multiorgan failure (MOF), septic complications and mortality were detected in the first group compared to the control, but the differences were not significant statistically. The total incidence of systemic inflammatory response syndrome (SIRS) and MOF were significantly different between the two groups (8 vs. 14; p < 0.05). Furthermore, the number patients recovering with complications were significantly less in the first group receiving modern synbiotic therapy compared to the control (p < 0.05). Finally, lower rate of late (over 48 hours) organ failure was detected in the first versus the control group (3.0% vs. 17.2%). CONCLUSIONS: The results suggest that early nasojejunal feeding with synbiotics may prevent organ dysfunctions in the late phase of severe acute pancreatitis. In addition, the data also indicate that the infection of pancreatic necrosis may be associated with early phase organ failure.

Alternative treatment modalities of infected pancreatic necrosis.

BACKGROUND/AIMS: Infected pancreatic necrosis diagnosed by fine needle aspiration (FNA) is generally considered an indication for surgery. Percutaneous drainage can postpone surgical intervention and in some cases can even have a therapeutic effect. Furthermore, targeted antibiotic therapy alone, based on bacterial cultures from FNA, can result in a full recovery. A retrospective analysis was carried out on the various treatment modalities of infected pancreatic necrosis. METHODOLOGY: Eighty patients with infected pancreatic necrosis were treated in the Department of Surgery, Teaching County Hospital, Györ, Hungary between 1998 and 2003. Seventy-four patients required surgical intervention, 12 of which underwent prior ultrasound or CT-guided drainage. RESULTS: In patients with previous percutaneous drainage the average time to first surgical intervention was 30 days (n=12). However, in those patients who did not undergo percutaneous drainage the time to initial surgical intervention was 15.6 days. This was statistically significant (p = 0.001). There was a full recovery in 3 out of the 15 patients, who underwent percutaneous drainage. This figure of 20% corresponds with that in the published literature. Three of the total 80 patients studied made a complete recovery when treated with targeted antibiotic therapy alone and did not require further radiological or surgical intervention. CONCLUSIONS: Our data indicate that percutaneous drainage can postpone surgical intervention. Furthermore, we demonstrate that percutaneous drainage alone can lead to full recovery in selected cases. In addition, targeted antibiotic therapy based on FNA may result in the complete recovery of a stable patient without requiring radiological or surgical intervention.

[A novel technique for the closure of the pancreatic remnant using jejunal serosa following distal pancreatectomy]. / Pancreas csonk szerotizálása distalis reszekció kapcsán.

Postoperative complication rate after distal pancreatectomy is as high as 10-30% in the published literature. Intraabdominal abscess formation and pancreatic fistula are the most common and clinically relevant complications, and they are thought to depend on surgical technique and skills. Using a novel method, we covered the pancreatic stump with the serosal surface of the first jejunal loop. Our aim was to compare the efficacy of this new technique to the traditional "stapling and handsewn suturing" method in terms of postoperative complication rate. Between 2002 and 2005, 50 patients, who underwent distal pancreatectomy, were randomized prospectively into two groups. In the first group of patients (n=23) the remnant of the pancreas was closed by the novel technique using the serosal surface of the first jejunal loop. In the second group (n=27) the pancreatic stump was closed in the traditional way using a combination of stapler and handsewn suture method. The incidence of postoperative pancreatic fistula and/or intra-abdominal abscess formation were compared using Fischer's test. Pancreatic fistula was defined as a loss of greater than 100 ml fluid drainage beyond postoperative day 5. We found a significantly lower postoperative complication rate using the novel technique compared to the traditional way to cover the pancreatic stump after distal pancreatectomy (8.7% vs. 33% (P = 0.0458). However, there was no significant difference in postoperative hospital stay. We concluded that using the serosal surface of the first jejunal loop is a simple, quick and secure method of closure of the proximal pancreas in terms of surgical practicability. This new technique significantly decreases the rate of postoperative fistula or abscess formation after distal pancreatectomy.

Multiorgan resection (including the pancreas) for metastasis of cutaneous malignant melanoma.

CONTEXT: Several studies have demonstrated improved survival after complete resection of hollow viscus gastrointestinal metastases of malignant melanoma. Patients with metastatic disease of intra-abdominal solid organs might also benefit from complete surgical resection. CASE REPORT: The authors report the case of a 22-year-old female patient with multiorgan abdominal metastases of cutaneous malignant melanoma, including the ovarium, jejunum, stomach and pancreas. All metastases were resected successfully. CONCLUSION: In highly selected patients with melanoma metastatic to intra-abdominal solid organs and hollow viscus gastrointestinal organs, aggressive attempts and complete surgical resection may improve survival.

[Current possibilities in the treatment of infected pancreatic necrosis]. / A fertozött pancreas necrosis kezelésének korszeru lehetoségei.

This is a retrospective study about 80 patients treated for infected necrosis of the pancreas between 1998-2003. Operation was performed in 74 patients, diagnosis was achieved by CT or U.S. guided drainage in 12 patients. In further 6 patients drainage and antibiotic therapy provided cure. In patients who were drained pre-operatively (n=12) the first surgical intervention was performed on average on the 30.2 days after admission, while in the group of patients without drainage surgery became necessary after 15.6 days. The difference is statistically significant (p = 0.001). Our data proved that in certain cases percutaneous drainage can delay surgical intervention. Our results also prove that percutaneous drainage itself can lead to complete cure. In our own practice this stands for about 20% of our patients. In 3 patients we proved that if the patients general condition is stable infected necrosis detected by fine needle aspiration can be successfully treated by antibiotic therapy, without surgical or further radiological intervention.

[Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study)]. / Jejunális táplálás és korszeru synbiotikum kombinációja súlyos acut pancreatitisben.

BACKGROUND: We showed previously that probiotics containing lactobacilli significantly improve the outcome of acute pancreatitis. "Synbiotic 2000", a new synbiotic composition with high colony forming unit (CFU) comprises four different types of pre- and probiotics. In this prospective, randomized, double-blind study we evaluated the role of "Synbiotic 2000" in the treatment of severe acute pancreatitis. METHODS: Patients with severe acute pancreatitis were randomized into two groups. Nasojejunal feeding was commenced within 24 hours after admission in both groups and continued for at least seven days. The first group of patients received four different lactobacilli preparations with 10(10) CFU, respectively, and prebiotics containing four bioactive fibres (inulin, beta-glucan, resistant starch and pectin) in addition. Patients in the second (control) group received only prebiotics. RESULTS: 62 patients with severe acute pancreatitis completed the study. Altogether 8 patients died. We detected lower incidence of multiorgan failure (MOF), septic complications and mortality in the first group compared to the control, but the differences were statistically not significant. The total incidence of systemic inflammatory response syndrome (SIRS) and MOF were significantly different between the two groups (8 vs. 14; p < 0.05). Furthermore, the number patients recovering with complications were significantly less in the first group receiving modern synbiotic therapy compared to the control (p < 0.05). Finally, we found lower rate of late (over 48 hours) organ failure in the first versus the control group (3.0% vs. 17.2%). CONCLUSION: Our results suggest that early nasojejunal feeding with synbiotic may prevent organ dysfunctions in the late phase of severe acute pancreatitis. In addition, our data also indicate that the infection of pancreatic necrosis may be associated with early phase organ failure.

Value of procalcitonin quick test in the differentiation between sterile and infected forms of acute pancreatitis.

BACKGROUND/AIMS: Authors analyzed the clinical value of procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreas necrosis verified by guided fine-needle aspiration (FNA). METHODOLOGY: In the prospective, controlled study data of 24 patients were evaluated. PCT-Q was performed in patients with necrosis--verified on computer tomography (CT scan)--and/or sepsis. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed, CT or ultrasound (US) guided fine-needle aspiration was performed with Gram staining and bacteriology. Positive FNA result was indication for surgery with repeated staining and bacteriology of the surgical specimen. RESULTS: Septic complications developed in 12 patients. Analyzing the results, fine-needle aspiration was more authentic with 92% sensitivity and 100% specificity, while sensitivity of PCT-Q test remained 75% and its specificity 83%. Comparing abscess with infected necrosis significantly higher procalcitonin values were detected in patients with necrosis. CONCLUSIONS: These results show that PCT-Q test is a possible non-invasive method which can be used besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2ng/mL) clearly suggest infection, while lower values do not exclude the possibility of local sepsis.

Long-term follow-up results of surgery for chronic pancreatitis.

BACKGROUND/AIMS: Based on a mean follow-up period of 86 months, the long-term results of 87 drainage and resection operations performed for chronic pancreatitis between 1990-94 were evaluated. METHODOLOGY: To evaluate the results, two questionnaires were filled out by the patients. The first was related to the pancreatitis and the long-term complications, the second was a Gastrointestinal Quality of Life Index questionnaire. Data of deceased patients were collected with the help of general practitioners. RESULTS: Based on the analysis of disease-related and quality of life questionnaire forms only 34% of the investigated patients could be classified as a group showing good results. There was a high incidence of long-term mortality (25%). Eighty-three percent of the deceased patients (18 patients) died after the seventh postoperative year. The most threatened group seems to be the alcoholic and insulin-dependent diabetic one. The combination of the two pathologies was the cause of death in a third of the cases. Insulin-dependent diabetes mellitus developed in 13 patients after an average of 3.9 years following surgery, mainly as a consequence of the irreversible and progressive nature of disease. The rate of disability was 51%. No significant difference could be demonstrated between the resected and the decompressed group according to either disability or late mortality rate. CONCLUSIONS: Based on these results, the authors wish to emphasize that in chronic pancreatitis the short-term follow-up results may be deceptive, and that the real outcome of the surgical treatment can only be expected five years following surgery.

[Membranous constriction of the colon caused by non-steroidal anti-inflammatory drugs--case report]. / Nem szteroid gyulladáscsökkentó gyógyszer indukálta membranosus vastagbélszúkület--esetismertetés.

A 79-year-old female patient with rheumatoid arthritis treated with NSAIDs on long-term developed iron-deficiency anaemia and subsequently subacute intestinal obstruction. Barium enema showed multiple diaphragm-like strictures. At colonoscopy the lumen of the ascending colon was divided into compartments by multiple thin circumferential mucosal membranes. Right hemicolectomy was carried out. The histology of the resected specimen confirmed diaphragm disease of the large bowel. Diagnosis is usually difficult, even at laparotomy, due to the poor external presence of the disease. Such lesions are rare (about 10 cases have been reported in the world literature) and are similar to those previously described in the small bowel. With the increasing world-wide use of NSAIDs, clinicians must be aware of this rare gastrointestinal complication, which may require emergency surgical intervention.

[Early jejunal nutrition with combined pre- and probiotics in acute pancreatitis--prospective, randomized, double-blind investigations]. / Korai jejunális táplálás pre- és probiotikummal történó kombinálása akut pancreatitisben--prospektív, randomizált, kettós-vak vizsgálatsorozat.

BACKGROUND: Development of infection of pancreatic tissue in patients with severe acute pancreatitis dramatically increases morbidity and mortality. Colonisation of the lower gastrointestinal tract and oropharynx, mostly with gram-negative but sometimes also gram-positive bacteria is known to precede the contamination of the pancreatic tissue by a few days. A few specific lactic acid bacteria such as Lactobacillus plantarum 299 were effective in preventing colonisation of the gut by potential pathogens, to reduce endotoxemia and to stimulate the gut-associated lymphatic system (GALT) and the immune system. METHODS: Patients with acute pancreatitis, arriving within 48 hours after onset of disease showing typical clinical picture and laboratory signs of pancreatitis (plasma amylase > 200 U/l, CRP > 150 mg/l and an Imrie-score = or > 3) were randomised into two groups During the first week the treatment group received a freeze-dried preparation containing 10(9) live Lactobacillus plantarum 299 together with an oat fibre substrate. The control group received a similar preparation, but the Lactobacillus plantarum 299 had been inactivated by heat. For seven days the treatment was repeated twice every day. The preparations were delivered to the hospital in sachets so the content was unknown to the investigators, staff and patients. RESULTS: Forty five patients completed the study before there was indication that one group differed from the other in a statistically significant way, at which time the study was discontinued and the code broken. At this time 22 patients had received treatment with live and 23 patients with heat-killed Lactobacillus plantarum 299. Infected necrosis and abscesses occurred in 1/22 (4.5%) in the treatment group vs. 7/23 (30%) (p = 0.023) in the control group. The length of stay was 13.7 days in the treatment group vs. 21.4 days in the control group (not statistically significant). CONCLUSIONS: Supplementing Lactobacillus plantarum 299 is an effective tool to prevent pancreatic sepsis, to reduce the number of operations and length of stay. The only patient who developed sepsis in the treatment group did so eight days after the treatment had been discontinued. One week treatment, as in the present study, is too short. It should be provided for at least 2 weeks, or more appropriately, as long as the patients are treated with antibiotics or have signs of GI colonisation.

[Role of procalcitonin rapid test in the differential diagnosis of uninfected and infected forms of acute pancreatitis]. / Procalcitonin gyorsteszt szerepe az akut necrotizáló pancreatitis steril és inficiált formáinak elkülönítésében.

We analysed the clinical value of the procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreatic necrosis verified by guided fine-needle aspiration (FNA). In a prospective, controlled study the results of 24 patients were evaluated during 2001. PCT-Q test was performed in patients with necrosis verified on CT scan and/or septic symptoms. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed CT or US guided fine-needle aspiration was performed with Gram staining and bacterial culture of the sample. Positive FNA result was indication for surgery with repeated staining and bacterial culture of the surgical specimen. Septic complications of pancreatic origin developed in 12 patients. Comparing the results fine-needle aspiration was more authentic with a sensitivity of 92% and a specificity of 100%, while the sensitivity of the PCT-Q test remained 75% and its specificity 83%. Comparing abscess and infected necrosis, significantly higher procalcitonin values were detected in patients with necrosis. These results show that PCT-Q test can be a possible non-invasive method besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2 ng/ml) clearly suggest infection of the necrosis, while lower values do not exclude the possibility of local septic progression.

[Surgical aspects of histologically unproven space-occupying lesions of the pancreas head]. / Szövettanilag tisztázatlan pancreasfeji térfoglaló folyamatok sebészi megoldásának dilemmái.

A suspected, but unproved malignant tumor in the head of the pancreas is a fairly common problem for surgeon. Even intraoperatively, differentiation between chronic pancreatitis and carcinoma is difficult. We try to give guidelines about what can be done with a pancreas head mass intraoperatively without previous cytology or histology. When do we have to achieve definite diagnosis at all costs, and how can we achieve it? Results of 40 intraoperative aspiration cytologies, performed for suspected pancreatic cancer were analysed. All of them were controlled by histology in the resected specimen. Intraoperative biopsy was false negative in 12.5% and the diagnosis was uncertain in 35%. These data show that a benign result by itself never excludes the presence of malignancy. If pathology will alter our decision about resection, all efforts should be made to confirm the diagnosis. On the other hand, in a case of a mass lesion with obstructive symptoms, cytology does not alter the need for surgical decompression, and some kind of resection is a reasonable option, even in case of chronic pancreatitis. Nihilistic approach in the case of pancreatic head mass with suspected but unproved malignancy is not justified. Pancreatoduodenectomy should be performed for all tumors even without histologic confirmation if an experienced team can perform it with low postoperative morbidity and mortality.

Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate.

OBJECTIVE: We investigated the effect of early jejunal feeding on septic complications and mortality rate in patients with acute pancreatitis in a two-phase, prospective, controlled study. METHODS: In the first, randomized phase of the study, conventional parenteral nutrition was compared with early (within 24-72 h after the onset of symptoms) enteral nutrition. Of 89 patients admitted with acute pancreatitis, 48 patients were randomized into a parenteral group (Rindex 10, Infusamin S, Intralipid 10%; 30 kcal/kg) and 41 patients into an enteral group (jejunal tube feeding; Survimed OPD; 30 kcal/kg). RESULTS: The rate of septic complications (infected pancreatic necrosis, abscess) was lower in the enteral group (P = 0.08, chi(2) test). In the second phase of the study, early jejunal feeding was combined with prophylactic imipenem (Tienam, 500 mg intravenously twice each day) when necrosis of the pancreas was detected by abdominal computed tomography. When the outcomes of 92 patients in the third group were compared with those of patients in the parenteral group, the rate of septic complications decreased significantly (P = 0.03). Multiple organ failure (P = 0.14) and mortality (P = 0.13) tended to decrease. CONCLUSIONS: We believe that the combination of early enteral nutrition and selective, adequate antibiotic prophylaxis may prevent multiple organ failure in patients with acute pancreatitis.