Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis.

OBJECTIVE: To evaluate the capacity of enteral nutrition, in comparison with the total parenteral nutrition (TPN) plus antibiotic therapy, for avoiding pancreatic necrosis infection in the severe acute pancreatitis. METHODS: In the period between October 1998 and September 2003, 87 patients met the inclusion criteria and took part in this research. Within the first week from their admission, 43 patients received TPN and 44 patients received total enteral nutrition (TEN). An adequate prophylactic antibiotic therapy was used in both groups. The severity of the manifestations was similar for both groups having a tomographic 'severity index' of 8 and an entry C-reactive protein of 208 and 203 mg/l, respectively. RESULTS: The group that received TPN suffered an organ failure in 79% of the cases, while the percentage showed by the group that received TEN was 31%; 88 and 25% of the patients in each group requiring a surgical intervention, respectively (p < 0.001). There was decreased presence of pancreatic necrosis infection in the group of patients that was supplied with TEN (20%) than in the group receiving TPN, where it reached 74% (p < 0.001). The death rate was significantly higher among the patients who received TPN, (35%), while for the patients who received TEN it was only 5% (p < 0.001). CONCLUSION: TEN could be used as a prophylactic therapy for infected pancreatic necrosis since it significantly diminished the necrosis infection as well as the mortality.

Gastrectomía con preservación pilórica para el cáncer gástrico temprano: una opción que mejora la calidad de vida / Pyloric-preserving gastrectomy for early gastric cancer: an option that improves quality of life

La gastrectomía preservando el píloro (GPP) fue desarrollada en 1967, para enfermedades benignas del estómago como la úlcera gástrica con buenos resultados, también se informó que las condiciones postoperatorias de los pacientes sujetos a GPP fueron buenas, por lo que recientemente, la GPP se ha utilizado en el tratamiento del cáncer gástrico temprano (CGT), con mejora en la calidad de vida con disminución de los síndromes posgastrectomía, como el dumping, hipoglucemia y pérdida de peso. Método: Es un estudio prospectivo comparativo analítico realizado en el servicio de cirugía 3B del Hospital Nacional Edgardo Rebagliati Martins, período marzo 2000 - mayo 2002, a 16 pacientes con diagnóstico de cáncer gástrico temprano de 205 pacientes con diagnóstico endoscópico e histológico de adenocarcinoma gástrico, a 4 pacientes se les realizó gastrectomía con preservación píloro más disección gangliomar D2 y a 11 pacientes se les realizó gastrectomía subtotal más disección gangliomar. En el año 1997, se realizó la primera resección polar superior con conservación pilórica en una paciente que portaba un tumor tipo I en la región yuxtacardial en curvatura menor, que no fue posible su extirpación por vía endoscópica y que fue cáncer temprano. Resultados: El cáncer gástrico temprano representa el 7,8% de los diagnosticados en este periodo en el HNERM. El 50% pacientes con cáncer temprano fueron de sexo masculino, el promedio de edad es de 55.3 años, el tipo macroscópico: II c que representa el 62.5%, microscópicamente el carcinoma indiferenciado con células en anillos de sello y el adenocarcinoma tubular bien diferenciado representan el 75% y 37.5% respectivamente, la lesión tumoral llegó a la submucosa 93.7% y mucosa 6.25%, la localización de la lesión fue corporo-antral 93.7%, a un paciente se realizó gastrectomía sub total proximal con anastomosis esófago-gástrica termino terminal...

The gastrectomy preserving the pylorus (GPP) was developed in 1967, for benign conditions of the stomach like gastric ulcer with good results. It was also informed that the postoperative conditions of the patients subject to GPP were good. Recently, the GPP has been used in the treatment of early gastric cancer (CGT), with an improvement in the quality of life, with a decrease of the post-gastrectomy syndromes, as dumping, hypoglycemia and the weight loss. Method: Analytic, comparative prospective study carried out in the surgery service 3B of the National Hospital Eduardo Rebagliati Martins, period March 2000 – May 2002, to 16 patients with diagnosis of early gastric cancer form a universe of 205 patients with endoscopic and histology diagnosis of gastric adenocarcinoma. In 4 patients, gastrectomy with preservation of pylorus and ganglionar dissection D2 was made and 11 patients were submitted to subtotal gastrectomy and gangliomar dissection. In the year 1997, we made the first superior resection with conservation of the pylorus in a patient that had a tumor in the yuxtacardial region in the lesser (smaller) curvature. Results: The early gastric cancer represents 7.8% of those diagnosed in this period in the HNERM. 50% patients with early cancer were male, the age average was 55.3 years, the macroscopic type: II c represented 62.5%. Microscopically the undifferentiated carcinoma with signet cell and the well differentiated tubular adenocarcinoma represented 75% and 37.5% respectively. The tumoral lesion compromised the submucosa in 93.7% and mucosa only in 6.25%. The localization of the lesion was corporo-antral in 93.7% of cases. In one case a proximal sub total gastrectomy with esophagusgastric TT ananstomosis was performed (6.2%). In four cases we carried out a corporal gastrectomy with pylorus preservation with gastro-gastro anastomosis TT (25%) and in 11 cases a sub total gastrectomy with gastro yeyunal anastomosis (68.75%)...

Laparoscopía en el estadiaje de cáncer gástrico avanzado. HNERM, 2001-2002 / Laparoscopy in the staging of advanced gastric cancer. HNERM, 2001-2002

Objetivo: Determinar el estadio del cáncer gástrico avanzado por laparoscopia, selección adecuada de pacientes operables y con posibilidad resectiva curativa, evitar laparotomías innecesarias, evaluar el costo utilidad del procedimiento. Método: Estudio prospectivo longitudinal que se llevó a cabo en el HNERM en el servicio de Cirugía 3ro B en el período Marzo 2001 a 2002. La población sujeta a estudio fue de 107 pacientes con diagnóstico de cáncer gástrico, a 80 pacientes se les realizó laparoscopía de estadiaje; categorizado como laparoscopía tipo I, II y III. Resultados: De los 80 pacientes, 63 (78,75%) fueron laparotomizados, operándose con cirugía resectiva curativa 58 pacientes (92%), cirugía derivativa paliativa 4 pacientes (6,4%) y laparotomía exploratoria a un paciente (1,6%). La laparoscopia tiene 94.4% de sensibilidad para determinar la operabilidad, y 100% de especificidad para el estadiaje, de esta patología, además un VP (+)=100%, VP (-)=98,4%, VG=98,7%. La sensibilidad para resecabilidad es 95.4%, especificidad de 100%, VP (+): 100%, VP(-)= 98.4%, VG= 98,7%. El costo diferencial de la laparotomía y la laparoscopía es de 1289,17 soles. Lo que disminuye el costo total de una laparotomía innecesaria en 38.51% en soles y 74% días de hospitalización. Conclusiones: La laparoscopía es un método válido para el estadiaje de cáncer gástrico avanzado por tener una Sensibilidad de determinar operabilidad es de 94,4 y resecabilidad curativa de 95,4% con especificidad del 100%. Permite la estandarización y selección apropiada del paciente con cáncer gástrico avanzado que será sometido a una cirugía resectiva curativa (Valor predictivo (+) de 100% un valor Predictivo Global de 98,75%), y tiene un impacto favorable en el costo utilidad del proceso, disminuyendo el costo total de una laparotomía en 38.51% en soles y 74% en días de hospitalización.

Objective: To determinate the staging of the advanced gastric cancer by laparoscopy, patients appropriate selection for healing surgical resection and operability, to avoid unnecessary laparotomy, to evaluate the cost utility of the procedure. Method: A prospective longitudinal study was performed at HNERM in the service of Surgery 3ro B from March 2001 to May 2002. The population subject to study belonged to 107 patients with diagnostic of gastric cancer; staging laparoscopy was performed in 80 patients. They were categorized as type I, II and III laparoscopy. Results: Of the 80 patients, 63 (78,75%) underwent laparotomy, being operated with surgical resection 58 patients (92%), palliative derivative surgery in 4 patients (6,4%) and exploratory laparotomy in one patient (1,6%). Therefore Laparoscopy has 95,4%, 100% of specificity for staging this pathology, also a VP (-) = 98,3%, VG = 98,7%, leading to put into practice this staging method for the advanced gastric cancer, avoiding unnecessary laparotomy and diminishing the cost. The cot differential is 1289,17 soles, it dimishes the total of an unnecessary laparotomy un 38.51% in soles and 74% in days of hospitalization. Conclusions: Laparoscopy is a valid methods for advanced gastric cancer staging, it has 94,4% of Sensitivity for operability, and 95,4% for resecarbility. It allows the standardization and the patient’s appropriate selection with advanced gastric cancer that will be subjected to a healing surgical resection (Predictive Value (+) of 100% a Global Predictive Value of 98,7%), and he/she has a favorable impact in the cost-utility of the process, dimishing the total cost of a laparotomy in 38.51% un suns and 74% in days of hospitalization.