Effect on intracranial pressure of abdominal compartment syndrome

Introduction: Mainly clinical studies have reported the increase in intracranial pressure (ICP), during intra-abdominal hypertension and abdominal compartment syndrome (ACS). Increased ICP has been reported during IAH up to 25mmHg ( intra-abdominal pressure IAP) by few experimental studies. However, there is no evidence for IAH more than 25mmHg regarding ICP, cerebral-spinal fluid pressure (CSFP), cerebral perfusion pressure (CPP) and spinal perfusion pressure (SPP). In our prospective experimental study, we investigated the effect of the IAH on the ICP, CFSP, CPP,SPP and we measured the lactate (lac) as an metabolic index of CNS ischaemia. Materials and methods: 11 pigs have been studied. After the preparation with the placement of the catheters for pressure monitoring and sample collection, pneumoperitoneum was established with helium. Initially we created pneumoperitoneum with IAP 25mmHg for 1 h, after that we increased the IAP to 40mmHg for another 1h and finally we released the helium and decompressed the abdomen. The pressures were monitored during the experiment and cerebral-spinal fluid sample were collected. Non-parametric tests were used for statistical analysis. Results: The results of IAP were the statistically significant increase of ICP (18,7mmHg to 25,4mmHg p=0,005), CSFP (13mmHg to 25mmHg p=0,007), and decrease of CPP (67,1mmHg to 54,4mmHg p=0,008), SPP (72,6mmHg to 54,4mmHg p=0,008) with elevation of the lactate (CSF) 1,5 to 2,17 p=0,011, during the phase T2 of the experiment. During T3 phase a paradoxical increase of CPP and SPP were observed, no statistically significant but above the critical level of 60mmHg and a decrease of the lactate (CSF), despite the further increase in the ICP and CSFP. Conclusion: The results of IAH are an increase of ICP, CSFP and a decrease of CPP,SPP. The low CPP and SPP, especially below the crucial level of the 60mmHg , will develop an elevation of lactate in CSF, because of the decrease cerebral blood flow- CNS ischaemia, irrespective of the level of ICP and SPP.Εισαγωγή: Από κλινικές κυρίως μελέτες έχει αναφερθεί, ότι η αυξημένη ενδοκοιλιακή πίεση(IAP) και το σύνδρομο κοιλιακού διαμερίσματος(ACS), προκαλεί αύξηση της ενδοκράνιας πίεσης(ICP), ενώ μερικές πειραματικές μελέτες σε πειραματόζωα δείχνουν αύξηση της ICP σε συνθήκες ενδοκοιλιακής πίεσης έως 25mmHg. Ωστόσο δεν υπάρχουν δεδομένα τι γίνεται σε συνθήκες πέραν των 25mmHg τόσο στις πιέσεις ενδοκράνια(ICP)- εγκεφαλονωτιαίου υγρού(CSFP), όσο και στις πιέσεις εγκεφαλικής(CPP) και νωτιαίας αιματικής ροής(SPP). Μέθοδος: συνολικά 11 χοίροι μελετήθηκαν στο πείραμα. Μετά τη προετοιμασία με τη τοποθέτηση καθετήρων για τη μέτρηση των πιέσεων και λήψη δειγμάτων, εφαρμόστηκε πνευμοπεριτόναιο με ήλιο, δημιουργώντας συνθήκες ενδοκοιλιακής υπέρτασης. Αρχικά εφαρμόσθηκε ενδοκοιλιακή πίεση 25mmHg, για 1 ώρα και κατόπιν ενδοκοιλιακή πίεση 40mmHg για άλλη 1 ενώ τελικά ακολούθησε αποσυμπίεση της κοιλιάς. Μετρήσεις έγιναν σε όλες τις φάσεις του πειράματος, ενώ δείγματα εγκεφαλονωτιαίου υγρού-αίματος ελήφθησαν για μέτρηση το γαλακτικού οξέως, ως δείκτης εγκεφαλικής ισχαιμίας. Μη παραμετρικές δοκιμασίες χρησιμοποιήθηκαν κατά την στατιστική ανάλυση. Αποτελέσματα: η αύξηση της ενδοκοιλιακής πίεσης είχε ως αποτέλεσμα τη στατιστικά σημαντική αύξηση της ICP (18,7mmHg σε 25,4mmHg p=0,005) και της CSFP (13mmHg σε 25mmHg p=0,007), με ταυτόχρονη μείωση της CPP (67,10mmHg σε 54,4 mmHg p=0,008)και της SPP (72,6mmHg σε 54,4mmHg p=0,008) με αύξηση του γαλακτικού οξέως στο ΕΝΥ( 1,5 σε 2,17 p=0,011) κατά την φάση Τ2 του πειράματος, ενώ κατά την φάση Τ3 παρατηρείται παράδοξη αύξηση τόσο της CPP και της SPP μη στατιστικά σημαντικής αλλά πάνω από το κριτικό όριο των 60mmHg, με ταυτόχρονη μείωση του γαλακτικού οξέως στο ΕΝΥ, παρά τη περαιτέρω μη στατιστικά σημαντική αύξηση της ICP και CSFP. Συμπεράσματα: Η ενδοκοιλιακή υπέρταση προκαλεί αύξηση της ICP και CSFP με συνοδό μείωση της CPP και της SPP,οι οποίες με τη σειρά τους λόγω μειωμένης αιμάτωσης του κεντρικού νευρικού συστήματος οδηγούν σε αύξηση του γαλακτικού οξέως στο ΕΝΥ, ως δείκτης ισχαιμίας, μόνο όταν μειωθούν κάτω από το κριτικό όριο των 60mmHg, ανεξαρτήτως τιμών ICP και CSFP

Single-centre comparative study of laparoscopic versus open right hepatectomy

BackgroundExpansion of laparoscopic major hepatectomy is still limited mainly due to the well-recognised technical difficulties compared to open surgery, and doubts regarding the oncological efficiency when major resections are required.MethodsPatients undergoing open right hepatectomy (ORH) were matched with patients undergoing laparoscopic right hepatectomy (LRH) and compared for perioperative outcomes.ResultsSeventy patients were included: 36 patients underwent LRH and 34 ORH. Operative time was significantly longer for LRH (median, 300 min vs. 180 min for ORH; p?<?0.0001). Intensive care unit (median, 2 days for LRH vs. 4 days for ORH; p?<?0.0001) and postoperative length of stay (5 days for LRH vs. 9 days for ORH; p?<?0.0001) were significantly shorter for LRH. Four laparoscopic cases were converted to open surgery. No significant difference in postoperative complications and mortality was observed between LRH and ORH. Among patients with colorectal carcinoma liver metastases, R0 resection was obtained in 20/21 (95%) cases after LRH, and in 20/25 (80%) after ORH (p?=?0.198). Mid-term overall survival did not significantly differ between the laparoscopic and the open group.ConclusionsLRH can be a safe, effective, and oncologically efficient alternative to open resection in selected cases. Extensive experience in hepatic and laparoscopic surgery is required

Predictors of actual five-year survival and recurrence after pancreatoduodenectomy for ampullary adenocarcinoma: results from an international multicentre retrospective cohort study

Background: pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence/survival.Methods: data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD patients with a confirmed head of pancreas or periampullary malignancy (June 1st, 2012-May 31st, 2015). Patients with AA who developed recurrence/died within five-years were compared to those who did not.Results: 394 patients were included and actual five-year survival was 54%. Recurrence affected 45% and the median time-to-recurrence was 14 months. Local only, local and distant, and distant only recurrence affected 34, 41 and 94 patients, respectively (site unknown: 7). Among those with recurrence, the most common sites were the liver (32%), local lymph nodes (14%) and lung/pleura (13%). Following multivariable tests, number of resected nodes, histological T stage &gt; II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin correlated with increased recurrence and reduced survival. Furthermore, ≥1 positive margin, PPFI and PNI were all associated with reduced time-to-recurrence.Conclusions: this multicentre retrospective study of PD outcomes identified numerous histopathological predictors of AA recurrence. Patients with these high-risk features might benefit from adjuvant therapy.</p

Does an extensive diagnostic workup for upfront resectable pancreatic cancer result in a delay which affects survival? Results from an international multicentre study

Backgrounds/aims: pancreatoduodenectomy (PD) is recommended in fit patients with a carcinoma (PDAC) of the pancreatic head, and a delayed resection may affect survival. This study aimed to correlate the time from staging to PD with long-term survival, and study the impact of preoperative investigations (if any) on the timing of surgery.Methods: data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD outcomes. Only PDAC patients who underwent an upfront resection were included. Patients who received neoadjuvant chemo-/radiotherapy were excluded. Group A (PD within 28 days of most recent preoperative computed tomography [CT]) was compared to group B (&gt; 28 days).Results: a total of 595 patents were included. Compared to group A (median CT-PD time: 12.5 days, interquartile range: 6-21), group B (49 days, 39-64.5) had similar one-year survival (73% vs. 75%, p = 0.6), five-year survival (23% vs. 21%, p = 0.6) and median time-todeath (17 vs. 18 months, p = 0.8). Staging laparoscopy (43 vs. 29.5 days, p = 0.009) and preoperative biliary stenting (39 vs. 20 days, p &lt; 0.001) were associated with a delay to PD, but magnetic resonance imaging (32 vs. 32 days, p = 0.5), positron emission tomography (40 vs. 31 days, p &gt; 0.99) and endoscopic ultrasonography (28 vs. 32 days, p &gt; 0.99) were not.Conclusions: although a treatment delay may give rise to patient anxiety, our findings would suggest this does not correlate with worse survival. A delay may be necessary to obtain further information and minimize the number of PD patients diagnosed with early disease recurrence.</p

Impact of SARS-CoV-2 pandemic on pancreatic cancer services and treatment pathways: United Kingdom experience.

INTRODUCTION The SARS-CoV-2 pandemic presented healthcare providers with an extreme challenge to provide cancer services. The impact upon the diagnostic and treatment capacity to treat pancreatic cancer is unclear. This study aimed to identify national variation in treatment pathways during the pandemic. METHODS A survey was distributed to all United Kingdom pancreatic specialist centres, to assess diagnostic, therapeutic and interventional services availability, and alterations in treatment pathways. A repeating methodology enabled assessment over time as the pandemic evolved. RESULTS Responses were received from all 29 centres. Over the first six weeks of the pandemic, less than a quarter of centres had normal availability of diagnostic pathways and a fifth of centres had no capacity whatsoever to undertake surgery. As the pandemic progressed services have gradually improved though most centres remain constrained to some degree. One third of centres changed their standard resectable pathway from surgery-first to neoadjuvant chemotherapy. Elderly patients, and those with COPD were less likely to be offered treatment during the pandemic. CONCLUSION The COVID-19 pandemic has affected the capacity of the NHS to provide diagnostic and staging investigations for pancreatic cancer. The impact of revised treatment pathways has yet to be realised

Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study

Background The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. Methods An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. Results A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment. Conclusion Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged