Antibiotic use in acute pancreatitis : an audit of current practice in a tertiary centre

Introduction: Intravenous antibiotic prophylaxis is not recommended in acute pancreatitis. According to current international guidelines antibiotics together with further intervention should be considered in the setting of infected necrosis. Appropriate antibiotic therapy particularly avoiding over-prescription is important. This study examines antibiotic use in acute pancreatitis in a tertiary centre using the current IAP/APA guidelines for reference. Methods: Data were collected on a consecutive series of patients admitted with acute pancreatitis over a 12 month period. Data were dichotomized by patients admitted directly to the centre and tertiary transfers. Information was collected on clinical course with specific reference to antibiotic use, episode severity, intervention and outcome. Results: 111 consecutive episodes of acute pancreatitis constitute the reported population. 31 (28%) were tertiary transfers. Overall 65 (58.5%) patients received antibiotics. Significantly more tertiary transfer patients received antibiotics. Mean person-days of antibiotic use was 23.9 (sd 29.7) days in the overall study group but there was significantly more use in the tertiary transfer group as compared to patients having their index admission to the centre (40.9 sd 37.1 vs 10.2 sd 8.9; P < 0.005). Thirty four (44%) of patients with clinically mild acute pancreatitis received antibiotics. Conclusions: There is substantial use of antibiotics in acute pancreatitis, in particular in patients with severe disease. Over-use is seen in mild acute pancreatitis. Better consideration must be given to identification of prophylaxis or therapy as indication. In relation to repeated courses of antibiotics in severe disease there must be clear indications for use

Preliminary experience in laparoscopic distal pancreatectomy using the AEON™ endovascular stapler

BackgroundThe aim of this study is to investigate the effects of using a new innovative endovascular stapler, AEON™, on the pancreatic leak rates and other outcome measures.MethodsIn a retrospective review of prospectively collected data from a secure tertiary unit registry, patients undergoing distal or lateral pancreatectomy were analyzed for any differences on pancreatic fistula rates, length of stay, comprehensive complication index (CCI), and demographics after using AEON™ compared with other commonly used staplers. Statistical significance was defined as &lt;0.05.ResultsThere were no differences in the demographics between the two groups totaling 58 patients over 2 years from 2019 to 2021. A total of 43 and 15 patients underwent pancreatic transection using other staplers and AEON™ endovascular stapler, respectively. The comparison of the two groups revealed a significantly reduced rate of mean drain lipase at postoperative day 3 with AEON™ (446 U/L) versus the other staplers (4,208 U/L) (p = 0.018) and a subsequent reduction of postoperative pancreatic fistula (POPF) from 65% to 20%. A reduction in the mean CCI, from 13.80 when other staplers were used to 4.97 when AEON™ was used, was also observed (p = 0.087). Mean length of stay was shorter by 3 days in the AEON™ group compared with that in the other staplers (6 and 9 days, respectively; p = 0.018).ConclusionAEON™ stapler when used to transect the pancreas demonstrated a significantly reduced pancreatic fistula rate, length of stay in hospital, and a leaning towards a reduced CCI. Its use should be further evaluated in larger cohorts with the encouraging results to determine whether this is possibly related to the technology used in the design of the AEON™ stapler

Comparison of Outcomes Between Open Major Hepatectomy Using CUSA and Laparoscopic Major Hepatectomy Using “Lotus” Liver Blade. A Propensity Score Matched Analysis

Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery.Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures.Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality.Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures

Amyand's hernia-a vermiform appendix presenting in an inguinal hernia: a case series

<p>Abstract</p> <p>Introduction</p> <p>A vermiform appendix in an inguinal hernia, inflamed or not, is known as Amyand's hernia. Here we present a case series of four men with Amyand's hernia.</p> <p>Case presentations</p> <p>We retrospectively studied 963 Caucasian patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyand's hernia (0.4%). A 32-year-old Caucasian man had an inflamed vermiform appendix in his hernial sac (acute appendicitis), presenting as an incarcerated right groin hernia, and underwent simultaneous appendectomy and Bassini suture hernia repair. Two patients, Caucasian men aged 36 and 43 years old, had normal appendices in their sacs, which clinically appeared as non-incarcerated right groin hernias. Both underwent a plug-mesh hernia repair without appendectomy. The fourth patient, a 25-year-old Caucasian man with a large but not inflamed appendix in his sac, had a plug-mesh hernia repair with appendectomy.</p> <p>Conclusion</p> <p>A hernia surgeon may encounter unexpected intraoperative findings, such as Amyand's hernia. It is important to be prepared and apply the appropriate treatment.</p

The influence of aprotinin in splachnic ischemia – reperfusion injury induced by pneumoperitoneum: experimental study in rats

The study of the pathophysiological effects of pneumoperitoneum in the circulatory system, respiratory system and especially splanchnic circulation resulted in numerous publications mainly in the 90s. Μeasurements of blood flow in the branches of the abdominal aorta showed a decrease, which was proportional to intraabdominal pressure. Either high intraabdominal pressure or atherosclerosis and stenoses of blood vessels may lead to more severe splanchnic ischemia, followed by the phase of reperfusion after pneumoperitoneum discontinuation. Therefore, it is argued that elevated intra-abdominal pressure during insufflation activates the mechanisms of ischemia - reperfusion syndrome.Ischemia - reperfusion syndrome includes pathophysiological changes induced by reperfusion of tissues being previously under ischemia. The primary step in the sequence of these processes is the production of free radicals, which have a direct toxic effect on the cells and trigger the inflammatory response. Ischemia – reperfusion syndrome in liver occurs frequently in clinical practice either due to vascular occlusion during hepatectomy or within hepatic transplantation. The reperfusion injury in the small intestine causes intestinal barrier disruption and migration of bacteria and endotoxins from the intestinal lumen into the portal and then the systemic circulation. The final induction of systemic inflammatory response (SIRS) involves the damage of distant organs (remote injury) and progression to multiple organ dysfunction syndrome (MODS).Aprotinin, a protease inhibitor, has been used in experimental protocols of ischemia - reperfusion with beneficial effects. The anti-inflammatory and antioxidant effects of aprotinin mainly lies on the reduction of the expression of adhesion molecules in the endothelium, the degradation of elastase and cathepsin, the reduced production of myeloperoxidase and phospholipase D by neutrophils and finally the decreased production of proinflammatory cytokines.We used 60 male Albino Wistar rats, which were randomly divided into three groups of 20 animals each. Τhe first was the Sham group. In the second group (Control group, C) pneumoperitoneum with constant pressure of 12mm Hg was maintained for 4 hours. In the third group (Aprotinin group, AP), 4 hour pneumoperitoneum was produced and also aprotinin was administered intraperitoneally in a similar dosage to that used in cardiac surgery. Control and aprotinin groups were randomly divided into two subgroups of 10 animals each with different duration of reperfusion (60 or 180 minutes). Hence subgroups were named as C60, C180, AP60 and AP180. Sacrifice of the rats followed. After middle abdominal and thoracic incision, blood was taken from the heart. Liver, small intestine and lung specimens were collected. Biochemical markers measured were: TNF- a, IL-6, ET-1, CRP, prooxidant – antioxidant balance (PAB) and carbonylated proteins. Hematoxylin - eosin staining was performed for the histological examination and various characteristics of inflammation were evaluated by two pathologists using a five-point scale. The values of most biomarkers in liver were significantly lower in aprotinin subgroups (at least in one or both of them). This result was confirmed by histological examination of liver specimens, since the lesions in animals given the drug were milder, particularly in AP180 subgroup. In the small intestine there was no clear biochemical result in favor of aprotinin. However, in the intestinal specimens inflammation of the small intestine was significantly lower in aprotinin groups. In the lung, both AP60 and AP180 subgroups exhibited milder inflammatory reaction. Finally, plasma measurements showed no difference between groups.In conclusion, aprotinin seems to reduce tissue damage caused by splachnic ischemia - reperfusion induced by pneumoperitoneum. This result, combined with the results of other similar experimental protocols, could be a forerunner for the design of clinical studies in order to investigate the anti-inflammatory effect of the compound in humans.Η μελέτη των παθοφυσιολογικών επιδράσεων του πνευμοπεριτοναίου στο κυκλοφορικό, στο αναπνευστικό και στη σπλαχνική κυκλοφορία οδήγησε σε πληθώρα δημοσιεύσεων κυρίως κατά τη δεκαετία του ’90. Oι μετρήσεις της αιματικής ροής στους κλάδους της κοιλιακής αορτής ανέδειξαν ελάττωση αυτής σε βαθμό ανάλογο της ενδοκοιλιακής πίεσης που εφαρμόζεται. Είτε σε υψηλές ενδοκοιλιακές πιέσεις είτε σε ασθενείς με αθηρωμάτωση και στενώσεις των αγγείων, το πνευμοπεριτόναιο οδηγεί σε σοβαρότερη σπλαχνική ισχαιμία, η οποία ακολουθείται από τη φάση της επαναιμάτωσης κατά την άρση του. Συνεπώς, υποστηρίζεται ότι το πνευμοπεριτόναιο ενεργοποιεί τους μηχανισμούς του συνδρόμου ισχαιμίας – επαναιμάτωσης. Το σύνδρομο ισχαιμίας – επαναιμάτωσης περιλαμβάνει τις παθοφυσιολογικές μεταβολές που επάγονται κατά την επαναιμάτωση ιστών που προηγουμένως ισχαιμούσαν. Πρωταρχικό βήμα στην αλληλουχία αυτών των διεργασιών είναι η παραγωγή ελευθέρων ριζών κυρίως οξυγόνου, αλλά και αζώτου, οι οποίες αφενός είναι κυτταροτοξικές, αφετέρου ενεργοποιούν τη φλεγμονώδη απάντηση. Το σύνδρομο ισχαιμίας – επαναιμάτωσης στο ήπαρ απαντάται συχνότατα στην κλινική πράξη είτε στα πλαίσια αγγειακού αποκλεισμού του οργάνου κατά τις ηπατεκτομές είτε στα πλαίσια μεταμόσχευσης. Η βλάβη από επαναιμάτωση στο λεπτό έντερο προκαλεί διαταραχή του εντερικού φραγμού και διαπίδυση μικροοργανισμών και τοξινών από τον εντερικό αυλό στην πυλαία και στη συνέχεια στη συστηματική κυκλοφορία. Η επαγωγή τελικώς της συστηματικής φλεγμονώδους απάντησης (SIRS) συνεπάγεται την βλάβη απομακρυσμένων οργάνων (remote injury) και την εγκατάσταση του συνδρόμου πολυοργανικής ανεπάρκειας (MODS). Η απροτινίνη, ένας αναστολέας πρωτεασών, έχει χρησιμοποιηθεί σε πειραματικά πρωτόκολλα ισχαιμίας – επαναιμάτωσης με ευεργετικά αποτελέσματα. Η αντιφλεγμονώδης και αντιοξειδωτική δράση της απροτινίνης έγκειται στην ελάττωση της έκφρασης των μορίων προσκόλλησης στο ενδοθήλιο, στην αποδόμηση της ελαστάσης και της καθεψίνης, στη μείωση της παραγωγής μυελοϋπεροξειδάσης και φωσφολιπάσης D από τα ουδετερόφιλα και τέλος στον περιορισμό της παραγωγής προφλεγμονωδών κυτταροκινών. Στην παρούσα εργασία χρησιμοποιήθηκαν 60 άρρενες επίμυες τύπου Albino Wistar, οι οποίοι χωρίστηκαν τυχαία σε τρεις ομάδες των 20 ζώων. Η πρώτη ομάδα (Sham group) ήταν η ομάδα της εικονικής παρέμβασης. Στη δεύτερη ομάδα (Control group, C) εγκαταστάθηκε πνευμοπεριτόναιο σταθερής πίεσης 12mm Hg διάρκειας τεσσάρων ωρών. Στην τρίτη ομάδα (Aprotinin group, AP) έγινε ό,τι και στην ομάδα ελέγχου και επιπλέον χορηγήθηκε ενδοπεριτοναϊκά απροτινίνη σε δοσολογία ανάλογη με αυτή που χρησιμοποιείται στις καρδιοχειρουργικές επεμβάσεις. Οι ομάδες ελέγχου και απροτινίνης διαιρέθηκαν τυχαία σε δύο υποομάδες των 10 ζώων, ανάλογα με το χρόνο επαναιμάτωσης (60 ή 180 λεπτά). Έτσι προέκυψαν υποομάδες με κωδική ονομασία C60, C180, AP60 και ΑΡ180. Ακολούθησε η θυσία των πειραματοζώων. Κατά τη θυσία πραγματοποιήθηκε αιμοληψία από τις καρδιακές κοιλότητες των πειραματοζώων και ελήφθησαν ιστοτεμάχια ήπατος, λεπτού εντέρου και πνεύμονα. Οι βιοχημικοί δείκτες που μετρήθηκαν ήταν: TNF-α, IL-6, ET-1, CRP, ισορροπία οξειδωτικών – αντιοξειδωτικών παραγόντων (PAB) και καρβονυλιωμένες πρωτεΐνες. Στα ιστολογικά παρασκευάσματα διενεργήθηκε χρώση με αιματοξυλίνη – ηωσίνη και έγινε αποτίμηση ποικίλων χαρακτηριστικών φλεγμονής από δύο παθολογοανατόμους με τη χρήση πενταβάθμιας κλίμακας. Οι τιμές των περισσότερων βιοχημικών δεικτών στο ήπαρ ήταν χαμηλότερες στη μία ή και στις δύο υποομάδες της απροτινίνης σε στατιστικά σημαντικό βαθμό. Το αποτέλεσμα αυτό επιβεβαιώθηκε από την ιστολογική εξέταση των παρασκευασμάτων με το καλύτερο σκορ να παρατηρείται στην υποομάδα AP180. Στο λεπτό έντερο δεν προέκυψε ξεκάθαρο αποτέλεσμα υπέρ των υποομάδων της απροτινίνης από τις μετρήσεις των βιοχημικών δεικτών ενώ η ιστολογική εικόνα ήταν αρκούντως πειστική ότι και στο λεπτό έντερο η απροτινίνη έδρασε προφυλακτικά. Στον πνεύμονα , οι υποομάδες ΑΡ60 και ΑΡ180 παρουσίαζαν ηπιότερη φλεγμονώδη αντίδραση, με τη δεύτερη να πλεονεκτεί στην ιστολογική εξέταση. Τέλος, στο πλάσμα δεν αναδείχθηκαν στατιστικά σημαντικές διαφορές μεταξύ των ομάδων. Συμπερασματικά, η απροτινίνη φαίνεται να ελαττώνει σημαντικά την ιστική βλάβη που προκαλεί η σπλαχνική ισχαιμία – επαναιμάτωση από πνευμοπεριτόναιο. Το αποτέλεσμα αυτό, σε συνδυασμό με τα αποτελέσματα και άλλων παρόμοιων πειραματικών πρωτοκόλλων, ανοίγει το δρόμο για το σχεδιασμό κλινικών μελετών που θα διερευνήσουν την αντιφλεγμονώδη δράση της ουσίας στον άνθρωπο

Liver Resection for Colorectal Hepatic Metastases after Systemic Chemotherapy and Selective Internal Radiation Therapy with Yttrium-90 Microspheres: A Systematic Review

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; Selective internal radiation therapy (SIRT) using yttrium-90 resin microspheres has been used together with systemic chemotherapy to treat patients with unresectable liver metastases. This study undertook the first systematic pooled assessment of the case profile, treatment and outcome in patients with initially inoperable colorectal hepatic metastases undergoing resection after systemic chemotherapy and SIRT. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; A systematic review of the literature was performed using Medline and Embase for publications between January 1998 and August 2017. Keywords and MESH headings “SIRT”, “Yttrium-99 radio embolization” and “liver metastases” were used. Reports on patients undergoing liver resection after SIRT for colorectal liver metastases were included. Case reports, reviews and papers without original data were excluded. The study protocol was registered with PROSPERO, (registration number: CRD42017072374). &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; The study population comprised of 120 patients undergoing liver resection after chemotherapy and SIRT. The conversion rate to hepatectomy in previously unresectable patients was 13.6% (109 of 802). All studies report a single application of SIRT. The interval from SIRT to surgery ranged from 39 days to 9 months. Overall, there were 4 (3.3%) deaths after hepatectomy in patients treated by chemotherapy and SIRT. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; This large pooled report of patients undergoing hepatectomy for colorectal liver metastases after chemotherapy and SIRT shows that 13.6% of patients with initially inoperable disease undergo resection with low procedure-related mortality.</jats:p

Evaluation of tumor M2-pyruvate kinase (Tumor M2-PK) as a biomarker for pancreatic cancer

Abstract Background Expression of the dimeric M2 isoenzyme of pyruvate kinase, termed Tumor M2-PK, is increased in some human cancers. This study evaluates the potential role of pre-operative Tumor M2-PK as a marker of prognosis in patients with pancreatic malignancy. Methods Seventy-three consecutive patients with a clinical diagnosis of pancreatic or peri-ampullary cancer were enrolled. Their median (range) age was 66 (23–83) years. Pre-operative samples of venous blood were taken for analysis of Tumor M2-PK. The full study protocol was approved by the North West Research Ethics Committee (protocol number 06/MRE08/69). Results The mean (standard deviation) plasma Tumor M2-PK in pancreatic/peri-ampullary malignancy was 60.3 (106.5) U/ml and 22 U/ml (SD: 12 U/ml) in benign disease (p  27 U/mL), Ca19-9 (> 39 U/ml), resection status, and disease stage were associated with poorer survival. Tumor M2-PK values greater than 27 U/ml were associated with inferior survival compared to those with lower values (hazard ratio 2.049, significantly increased risk of death, p = 0.042). Conclusion This preliminary study shows that an elevated level of Tumor M2-PK (with a cutoff threshold of 27 U/mL) measured pre-operatively is associated with poorer prognosis in patients with pancreatic and peri-ampullary cancer

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Hepatectomy: A Systematic Review and Meta-Analysis.

ObjectivesMortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion (SHVE) compared to a Pringle maneuver in hepatic resection reduces rates of morbidity and mortality.MethodsA systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and SCOPUS for comparative studies meeting the inclusion criteria. Pooled odds ratios or mean differences were calculated for outcomes using either fixed- or random-effects models.ResultsSix studies were identified: three randomised controlled trials and three observational studies reporting a total of 2,238 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, blood loss, transfusion requirements, air embolism, liver failure and multi-organ failure in the SHVE group. Rates of hepatic vein rupture, post-operative hemorrhage, operative and warm ischemia time, length of stay in hospital and intensive care unit were not statistically significant between the two groups.ConclusionPerforming SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle maneuver. The results of this meta-analysis are based on studies where tumors were adjacent to major vessels. Further RCTs are required to validate these results.Clinical trial registrationPROSPERO (CRD42020212372) https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=212372