Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy.

BACKGROUND: Pancreatic fistula and intra-abdominal fluid collection are the commonest complications after distal pancreatectomy. Several techniques have been described to achieve perfect closure of the stump. METHODS: In this randomized clinical trial the stapler technique was compared with stapling combined with a seromuscular patch. Seventy patients who underwent distal pancreatectomy were randomized between January 2002 and December 2006 to either closure of the pancreatic stump by stapler (35 patients) or closure by stapler and covering with a seromuscular patch of jejunum (35). The primary endpoint was the rate of postoperative fistula and/or intra-abdominal fluid collections. RESULTS: The overall rate of these pancreas-related complications was higher in the stapling-alone group. However, rates of clinically relevant postoperative complications (grade B or C fistula and/or fluid collection requiring treatment) were comparable. The reintervention rate and median hospital stay were similar in both groups. CONCLUSION: Covering the stapled pancreatic remnants with a seromuscular patch is a simple method that decreased overall pancreas-related complications such as fistula. This technique did not affect clinically relevant outcomes as severe complications requiring treatment were similar with both techniques.

Preventive strategies for septic complications of acute pancreatitis.

The diagram of the mortality of acute pancreatitis is characterized by two distinct peaks, in a similar manner to other generalized acute inflammatory responses. In the first phase, which is characterized by "hyper-inflammatory" mechanisms, death occurs due to overwhelming SIRS and subsequent multi-organ failure. The second peak of death is usually detected much later, at least two weeks after the onset of acute pancreatitis. Infection in necrotising pancreatitis is frequently observed in this so-called "compensatory antiinflammatory" phase. Since there has been no effective therapy evolved to prevent the activation of inflammatory and proteolytic cascades, the treatment of acute pancreatitis is merely symptomatic. Adequate fluid resuscitation and analgesia are the mainstays of treatment. In case of development of multi-organ failure, extensive medical and ventilatory supportive therapy is usually necessary. However, recent studies suggested certain methods might decrease the incidence of infection in pancreatic necrosis, which is usually due to bacterial translocation from the gut. Numerous attempts have been published in the literature to decrease the frequency of septic complications. Furthermore, the outcome of studies favouring antibiotic prophylaxis in acute pancreatitis were debatable. The development of multi-resistant strains of Gram-positive bacteria and Candida, due to long-term antibiotic use, is a strong argument against the indication of prophylactic antibiotic use. Recently, various clinical studies aimed to decrease bacterial translocation, including probiotic use and enteral feeding as part of the treatment. This paper provides a systematic review on data available in the evidence based literature on the use of antibiotics and the role of alternative and supportive therapy in the treatment of severe acute pancreatitis.

[Early jejunal feeding in acute pancreatitis: prevention of septic complications and multiorgan failure]. / Korai jejunális táplálás akut pancreatitisben: a szeptikus szövódmények és a sokszervi elégtelenség megelózésének lehetósége?

Authors evaluate the effect of early jejunal feeding on septic complications and mortality in acute pancreatitis, based on the results of a two-phase, prospective, randomized study. In the first part of the study they compared the conventional parenteral nutrition with early (started within 24 hours) enteral nutrition in a prospective, randomized trial on 89 patients. Forty-eight patients were randomized into the parenteral group "A" (Rindex 10, Infusamin S, Intralipid 10%: 30 kcal/kg) and 41 patients into the enteral group "B" (fed by nasogastric jejunal tube Survimed OPD, 30 kcal/kg). The rate of septic complications (infected necrosis, abscess, infected pseudocyst) were significantly lower in the enteral group (p = 0.08 chi-square test). In the second phase of the study early jejunal feeding was combined with imipenem prophylaxis (Tienam, 2 x 500 mg i.v.) in the necrotizing cases detected by CT scan. According to the results of 92 patients the rate of septic complications (p = 0.03), multiple organ failure (p = 0.14), and mortality (p = 0.13) were further reduced in this group. Authors believe that combination of early enteral nutrition and a selective, adequate antibiotic therapy may give a chance for prevention of multiple organ failure.

[Correlation of alcohol consumption and pancreatitis in Hungary]. / Az alkoholfogyasztás és a pancreatitis magyarországi összefüggései.

Alcoholic etiology of acute pancreatitis is outstanding high in Hungary. The aim of this retrospective study was to analyse the etiology of patients of 5 years. Between 1990 and 1994 altogether 374 patients were admitted with acute pancreatitis, which is three and half times higher than between 1970 and 1974. From the 374 cases 220 had alcoholic and only 115 had biliary etiology. Altogether in 127 patients developed necrosis, the rate of alcoholic etiology was 80% in this subgroup. During the last two decades the trend of alcohol consumption became one of the most burning question in Hungary. Based on the Jellinek's formula alcohologists estimate the number of alcoholics more than one million. The number of pancreatitis related death multiplied almost four times between 1970 and 1994. The doubling of alcohol consumption was practically simultaneous with the increase of morbidity and mortality of pancreatitis. Hungary shows the most disfavourable distribution of drink varieties among the high-consuming countries in Europe.

[Single layer continuous absorbable sutures for gastrointestinal anastomosis]. / Egyrétegú, tovafutó, felszívódó varratsorral készült anasztomózis a gastrointestinalis sebészetben.

Authors evaluated the safety of single layer continuous sutured anastomosis technique with two different types of absorbable sutures in 252 anastomoses performed on 178 patients. In the prospective, randomized study 5 oesophagus, 26 stomach, 117 small intestine, 32 colonic, 29 pancreatic and 43 biliary anastomoses were performed. In 136 cases poliglecaprone 25 (Monocryl), in 116 cases glycomer 631 (Biosyn) were used. All procedures were carried out by the same surgeon. Anastomosis related complication was detected in 7 cases (2.8%), some kind of anastomosis insufficiency--including minor leakage--in 5 cases (2.0%), but reoperation only in one case (0.4%) was required. There was no anastomosis related death. Authors overview the advantages of the technique, which is safe, cheap, easy to carry out, physiological and least harmful to the blood supply, so they recommend its use in the gastrointestinal surgery as a standard procedure.

[Long-term follow-up results of surgery for chronic pancreatitis]. / Krónikus pancreatitis miatt végzett mútéteink hosszú távú eredményei.

Authors evaluate the late results of 51 operated patients by decompression or resection procedure for chronic pancreatitis between 1990-94, based on a follow-up period of 86 months. Only 34% of the 47 investigated patients could be classified as "good" results group--it is the half part of the good results of their former study based on 20 months follow-up period. The incidence of late deaths was very high--27.6%. Eighty-five percent of all the lost patients (11 pts) died after the seventh postoperative year. The most threatened group seems to be the alcoholic and insulin-dependent diabetic patients. This combination was the cause of death in third part of the cases. IDDM developed altogether in 9 patients, on average 3.7 years after the operation, namely it was the consequence of the irreversible progressive natural history of disease. The rate of disability is 44%, and it is significantly higher in the resected group than after decompression, just like the late mortality rat. Based on their results authors emphasise that in chronic pancreatitis the short-term (20-36 months) follow-up results may be deceptive, real outcome of the surgical treatment could be expected only after 5 years postoperatively.

[Experience with the surgical management of Vater's ampulla tumors]. / Vater-papilla tumorok sebészi kezelésével szerzett tapasztalataink.

The article reviews our experience about tumours of the papilla of Vater. 30 patients were operated on between 1996-1999. The mean age was 58 years, the leading symptom (73%) was jaundice. In 23 patients preoperative ERCP was successful and was completed in 15 cases with EST, in 8 cases with biliary drainage. In 3 patients--despite benign endoscopic histology--intraoperative frozen section, and in one patient final histology confirmed malignancy. Altogether in 27 patients was malignant transformation of the papilla observed. In 15 cases pylorus-preserving pancreatoduodenectomy (PPPD), in 2 cases local excision (LE), while in 10 patients palliative procedures were performed. Resection rate (PPPD + LE) was 63%, while radical resection (PPPD) was performed in 55.5% of all cases. During 26 months mean follow-up survival rate was altogether 74%, and 80% in radically resected patients. We review the literature, describe the difficulty of histological and describe our experience and practice in the treatment of this rare tumour.

[Inguinal hernia repair with mesh plug technique (initial experiences with a new, tension-free surgical method)]. / Inguinalis sérvek rekonstrukciója mesh plug technikával (kezdeti tapasztalataink egy új, feszülésmentes mútéti eljárással).

Majority of inguinal hernia repair are performed in Hungary by traditional surgical techniques, reconstruction under tension (Bassini, Kirschner, Shouldice). Hernia surgery underwent a revolutionary change from the 80's. Set out from the United States, tension-free methodologies (Lichtenstein, laparoscopy, mesh plug) have spread worldwide, of which early and late results--especially recurrence rate--are significantly better than the formerly used techniques. Authors introduce the surgical technique of mesh plug hernioplasty and their promising experiences after the first 80 operations.

Use of different absorbable sutures for continuous single-layer anastomosis in the gastrointestinal tract. A prospective, randomized study.

BACKGROUND AND AIMS: A prospective, randomized study was designed to test the safety of the single-layer continuous anastomosis technique in gastrointestinal surgery. Results from the use of two different sutures were compared in relation to postoperative complications. MATERIAL AND METHODS: The safety of a single-layer continuous technique using two different types of absorbable suture was studied in 247 anastomoses performed on 183 patients between 1996 and 1997. There were 26 gastric, 117 small-bowel, 32 colonic, 29 pancreatic and 43 biliary anastomoses in the study. In 134 cases, Poliglecaprone 25 (Monocryl, Johnson & Johnson) was used, and in 113 cases Glycomer 631 (Biosyn, USSC). All procedures were carried out by the same surgeon. RESULTS: Anastomosis-related complications were detected in 7 patients (2.8%). Anastomotic failures including minor leakage occurred in 5 cases (2.0%). Reoperation was required in only 1 patient (0.4%), and there were no deaths. No difference was found in the dehiscence rate between the two types of absorbable material (1.5% with Monocryl and 2.6% with Biosyn; p = 0.5). CONCLUSION: Compared with other techniques used for gastrointestinal anastomosis, this technique is safe and easy to apply using either suture material.

Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis.

BACKGROUND: Microbial infection of the pancreatic tissue in patients with severe acute pancreatitis increases the morbidity and mortality rates. Colonization of the lower gastrointestinal tract and oropharynx with Gram-negative, but sometimes also Gram-positive, bacteria precedes contamination of the pancreas. The aim of this study was to determine whether lactic acid bacteria such as Lactobacillus plantarum 299 could prevent colonization of the gut by potential pathogens and thus reduce the endotoxaemia associated with acute pancreatitis. METHODS: Patients with acute pancreatitis were randomized into two double-blind groups. The treatment group received a freeze-dried preparation containing live L. plantarum 299 in a dose of 109 organisms, together with a substrate of oat fibre, for 1 week by nasojejunal tube. The control group received a similar preparation but the Lactobacillus was inactivated by heat. RESULTS: A total of 45 patients completed the study. Twenty-two patients received treatment with live and 23 with heat-killed L. plantarum 299. Infected pancreatic necrosis and abscesses occurred in one of 22 patients in the treatment group, compared with seven of 23 in the control group (P = 0.023). The mean length of stay was 13.7 days in the treatment group versus 21.4 days in the control group (P not significant). CONCLUSION: Supplementary L. plantarum 299 was effective in reducing pancreatic sepsis and the number of surgical interventions.