Chronic pancreatitis.

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges.

Is smaller necessarily better? A systematic review comparing the effects of minilaparoscopic and conventional laparoscopic cholecystectomy on patient outcomes.

BACKGROUND: In recent years, minilaparoscopic cholecystectomy (MLC; total size of trocar incision < 25 mm) has been increasingly advocated for the removal of the gallbladder, due to potentially better surgical outcomes (e.g., better cosmetic result, reduced pain, shorter hospital stay, quicker return to activity), but an evidence-based approach has been lacking. The current systematic review was undertaken to evaluate the importance of total size of trocar incision in improving surgical outcomes in adult laparoscopic cholecystectomy (LC). METHODS: The literature was systematically reviewed using MEDLINE and EmBASE. Only randomized controlled trials in English, investigating minilaparoscopic versus conventional LC (total size of trocar incision > or = 25 mm) and reporting pain scores were included. Quantitative analyses (meta-analyses) were performed on postoperative pain scores and other patient outcomes from more than one study where feasible and appropriate. Qualitative analyses consisted of assessing the number of studies showing a significant difference between the techniques. RESULTS: Thirteen trials met the inclusion criteria. There was a trend towards reduced pain with MLC compared with conventional LC, without reduction in opioid use. Patients in the MLC group had slightly reduced length of hospital stay, but there were no significant differences for return to activity. The two interventions were also similar in terms of operating times and adverse events, but MLC was associated with better cosmetic result (largely patient rated). There was a significantly greater likelihood of conversion to conventional LC or to open cholecystectomy in the MLC group than there was of conversion to open cholecystectomy in the conventional LC group [OR 4.71 (95% confidence interval 2.67-8.31), p < 0.00001]. CONCLUSIONS: The data included in this review suggest that reducing the size of trocar incision results in some limited improvements in surgical outcomes after LC. However, it carries a higher risk of conversion to conventional LC or open cholecystectomy.

Clinical relevance of intra-abdominal hypertension in patients with severe acute pancreatitis.

OBJECTIVES: Intra-abdominal hypertension (IAH) contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of abdominal compartment syndrome (ACS). This study aims to investigate the clinical significance of IAH in patients with severe acute pancreatitis (SAP). METHODS: Patients admitted to intensive care with SAP underwent daily measurement of intra-abdominal pressure (IAP), recording of the clinical data, and calculation of 4 organ dysfunction scores. RESULTS: Among 18 patients with SAP, 11 (61%) developed IAH (median, 20 mm Hg), whereas 10 (56%) developed ACS. The IAP correlated significantly with the 4 organ dysfunction scores; the scores were significantly higher when IAH existed than when it did not. The admission IAP correlated significantly with the duration of intensive care stay. Patients who developed IAH/ACS had significantly higher organ failure score and greater mortality compared with those who did not. Laparotomy and drainage reduced the IAP by a median of -11 mm Hg and relieved the IAH/ACS in all patients. CONCLUSIONS: Intra-abdominal hypertension and ACS are frequent findings in patients with SAP and are associated with deterioration in organ function. Intra-abdominal pressure correlates with the severity of organ failure, and a high admission IAP is associated with prolonged intensive care stay.

Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery.

BACKGROUND/PURPOSE: Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce. METHODS: Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases. RESULTS: There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219). CONCLUSIONS: Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.

Dietary antioxidant lack, impaired hepatic glutathione reserve, and cholesterol gallstones.

BACKGROUND: Theoretical considerations and experimental studies suggest a causal connection between micronutrient antioxidant insufficiency and the development of human gallstones. METHODS: Fasting plasma/serum samples from 24 patients with cholesterol gallstones-on unchanged lifestyles-were analysed for the four main micronutrient antioxidants, glutathione and factors that impact or report upon glutathione homeostasis. The results were assessed by comparison with laboratory referent ranges. RESULTS: The vitamin E:cholesterol ratio was lower in patients than controls (P=0.021) as also concentrations of beta-carotene (P=0.001) and vitamin C (P=0.001) but not selenium (P=0.280). A fall in plasma glutathione (P=0.001) was also accompanied by lower values of pyridoxyl-5-phosphate (the coenzyme that participates in vitamin B6-dependent enzyme reactions) which is involved in glutathione biosynthesis (P<0.001), and of folate (P=0.012) but not vitamin B12 (P=0.377) that participate in its regeneration via the methionine-homocysteine pathway. Despite these defects, values for plasma homocysteine were not significantly different from controls (P=0.092)-an anomaly rationalised by poor levels of precursor methionine (P=0.003) and cysteine (P=0.046). CONCLUSIONS: Micronutrient antioxidant-including sulphur amino acid-lack, with disturbed glutathione homeostasis, are features of cholesterol gallstone disease.

Interrogation of patient data delivered to the operating theatre during hepato-pancreatic surgery using high-performance computing.

OBJECTIVE: The Op3D visualization system allows, for the first time, a surgeon in the operating theatre to interrogate patient-specific medical data sets rendered in three dimensions using high-performance computing. The hypothesis of this research is that the success rate of hepato-pancreatic surgical resections can be improved by replacing the light box with an interactive 3D representation of the medical data in the operating theatre. MATERIALS AND METHODS: A laptop serves as the client computer and an easy-to-use interface has been developed for the surgeon to interact with and interrogate the patient data. To date, 16 patients have had 3D reconstructions of their DICOM data sets, including preoperative interrogation and planning of surgery. RESULTS: Interrogation of the 3D images live in theatre and comparison with the surgeons' operative findings (including intraoperative ultrasound) led to the operation being abandoned in 25% of cases, adoption of an alternative surgical approach in 25% of cases, and helpful image guidance for successful resection in 50% of cases. CONCLUSIONS: The clinical value of the latest generation of scanners and digital imaging techniques cannot be realized unless appropriate dissemination of the images takes place. This project has succeeded in translating the image technology into a user-friendly form and delivers 3D reconstructions of patient-specific data to the "sharp end"-the surgeon undertaking the tumor resection in theatre, in a manner that allows interaction and interpretation. More time interrogating the 3D data sets preoperatively would help reduce the incidence of abandoned operations-this is part of the surgeons' learning curve. We have developed one of the first practical applications to benefit from remote visualization, and certainly the first medical visualization application of this kind.

Comparison of task performance of the camera-holder robots EndoAssist and Aesop.

BACKGROUND: Two robotic laparoscopic camera-holders, Endo Assist and Aesop 3000, are compared from a system design viewpoint measuring the time taken to perform certain tasks by the operator. METHODS: EndoAssist and Aesop 3000 robots were tested in a simulated environment. EndoAssist was controlled via a headset-mounted motion axis selection sensor, while Aesop was voice activated. A series of simple and complex tasks were performed moving the camera to different targets. The performance of each task was video taped, and the time from onset to the end of the task was taken from the recording. RESULTS: The results showed the EndoAssist robot to be significantly quicker for most of the tasks studied. This was attributed to increased accuracy of movement in EndoAssist in comparison to the voice recognition errors evident while operating Aesop. CONCLUSION: The time taken to perform tasks yields significantly more information about the integrated human-robot system than simply studying the speed of movement of the robot.

Virtual reality laparoscopic simulator for assessment in gynaecology.

A validated virtual reality laparoscopic simulator minimally invasive surgical trainer (MIST) 2 was used to assess the psychomotor skills of 21 gynaecologists (2 consultants, 8 registrars and 11 senior house officers). Nine gynaecologists failed to complete the VR tasks at the first attempt and were excluded for sequential evaluation. Each of the remaining 12 gynaecologists were tested on MIST 2 on four occasions within four weeks. The MIST 2 simulator provided quantitative data on time to complete tasks, errors, economy of movement and economy of diathermy use--for both right and left hand performance. The results show a significant early learning curve for the majority of tasks which plateaued by the third session. This suggests a high quality surgeon-computer interface. MIST 2 provides objective assessment of laparoscopic skills in gynaecologists.

BPDZ 154 activates adenosine 5'-triphosphate-sensitive potassium channels: in vitro studies using rodent insulin-secreting cells and islets isolated from patients with hyperinsulinism.

A novel ATP-sensitive potassium channel (K(ATP)) channel agonist, BPDZ 154 (6,7-dichloro-3-isopropylamino-4H-1,2,4-benzothiadiazine 1,1-dioxide), was synthesized, and its effects on insulin-secreting cells were evaluated using electrophysiology, (86)Rb(+) and (45)Ca(2+) efflux, and RIA determinations of insulin secretion. BPDZ 154, an analog of diazoxide, inhibited both glucose-induced insulin secretion from isolated perifused islets and the secretion of insulin induced by glucose and tolbutamide. These effects were mediated by the activation of ATP-sensitive potassium channels because BPDZ 154 induced a concentration-dependent increase in channel activity that was inhibited by the sulfonylurea tolbutamide and the imidazoline efaroxan. In beta-cells isolated from patients with either nontypical hyperinsulinism (preserved K(ATP) channel function) or from the control areas of the pancreas of patients with focal hyperinsulinism, BPDZ 154 activated K(ATP) channels and was found to be more effective and less readily reversible than diazoxide. By contrast, it was not possible to activate K(ATP) channels by either diazoxide or BPDZ 154 in beta-cells from patients with hyperinsulinism as a consequence of defects in K(ATP) channel function. In beta-cells isolated from a patient with pancreatic insulinoma, K(ATP) channels were readily recorded and modulated by BPDZ 154. These data suggest that BPDZ 154 or BPDZ 154-like compounds may have therapeutic potential in the treatment of certain forms of hyperinsulinism.