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.

[Late complications of pancreatic injuries following blunt abdominal trauma]. / Tompa hasi traumát követö pancreas-sérülések késöi szövödményei.

In connection with three successfully operated cases authors are treating the types of late pancreatic complications after blunt abdominal trauma. It is emphasized that the preoperative diagnosis is difficult. Many times weeks or months pass away after the trauma without any symptoms and only developed complication can be noticed first. The importance of the first provision and the need for a careful examination of the pancreas at operation is underlined. In the case of the less suspicion of pancreatic injury they suggest wide, adequate drainage. At last they call attention to the responsibility of the surgeon making the first operation.

[Evaluation of palliative surgical procedures in tumors of the pancreatic head]. / Pancreasfejtumorok miatt végzett palliatív mütéti beavatkozások értékelése.

Authors studied 87 patients with obstructive jaundice secondary to unresectable cancer of the head of the pancreas undergoing palliative biliary bypass procedure. They compared the four different types of biliodigestive anastomoses regarding to the postoperative morbidity, the mortality, the late complications and the survival. Their data suggest that Roux-en-Y choledochojejunostomy with prophylactic GEA is the optimal palliation. They studied the incidence of a second operation for duodenal obstruction. Comparing the operative mortality of each group they suggest that prophylactic gastroenterostomy adds no risk to patients, but they advise it's routine use only with choledochoenteric bypass and in lack of distant metastasis. Survival was significantly higher (p = 0.015) in the group of patients above 70 years. This data support the slower progression of the pancreatic tumor in old-age. They analyse three different factors affecting operative mortality. It was not related to the depth of jaundice and the age of the patients, but it was in a very close correlation with the preoperative blood urea nitrogen level. Authors suppose this parameter a simply and useful criteria in the selection for non-operative palliative procedures.

[Delayed gastric emptying as a frequent complication of pylorus-preserving pancreatoduodenectomy]. / Elhúzódó gyomorürülés, a pylorus-megtartásos pancreatoduodenectomia gyakori szövödménye.

The most common complication of the pylorus-preserving pancreatoduodenectomy is delay in gastric emptying. Authors present on 18 pylorus-preserving resection performed in the County Hospital of Gyór and Nyíregyháza between 90-92. Delayed gastric emptying (DGE) developed altogether in 7 patients, median length of prolongation of gastric suction was 13.6 days. None of patients had reoperation. Comparing the two groups according to the type of duodeno-jejunostomy, the complication was higher after end to side anastomosis. Authors review the literature and comparing to their own results they study the mechanism, the possible causes and the therapy of DGE. They emphasize that in can be managed conservatively with patience.

[Colonic complications associated with acute necrotizing pancreatitis]. / Akut nekrotizáló pancreatitishez társuló vastagbélszövödmények.

Authors found colonic involvement in 9 cases of the 83 patients who have undergone surgical procedure for acute pancreatitis (10.8%). The form of the complications were inoperable extensive necrosis in two, resectable isolated necrosis in four and colo-cutaneous fistula in three cases. Acute extrapancreatic fat necrosis usually caused segmental necrosis of the colon while abscess generally led to fistulization. Complications based rather on ischaemic damage of mesocolon than direct enzymatic influence. Five patients died. Analysing this late, severe involvement, which appeared average on 18-th day, authors try to find relationships between pathomechanism, therapy and mortality rate.

[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.

[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.

The role of diagnostic laparoscopy in staging of pancreatic cancers.

Authors report elective diagnostic laparoscopy, and the role of this method in evaluating operability of pancreatic cancer. At their department 11 diagnostic laparoscopic procedures of pancreatic cancer were performed during the last 5 years. In 3 cases tumor proved to be resectable despite preoperative imaging results of unresectable condition. On the basis of international literature authors give brief summary of indications, cost and benefit of diagnostic laparoscopy, and its place in the diagnostic algorythm of pancreatic cancer.