Artificial nutrition in severe acute pancreatitis: an evolving concept.

We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index

Anorectal manometry : standardisation of the execution technique.

Anorectal manometry is the basic investigation for the study of anorectal function. The lack of a standard execution technique and of any common definition of the manometric parameters constitutes a major limitation. The aim of the present study is to propose a standard technique for performing manometry. In addition we also focus on those manometric parameters that are easily identified and interpreted for the systematic study of a proctological patient. The protocol used is organised in three phases: (i) tests with a radial channel probe with continuous extraction, which provide information on the length of the anal canal and on the precise site of maximum pressure; (ii) tests with a radial channel probe with stationary extraction, which does not involve reflex contraction of the sphincter apparatus and therefore permits better evaluation of sphincter pressure when the muscles are relaxed as well as the identification of slow and ultra-slow waves; (iii) tests with a helicoidal probe and a balloon for the evaluation of the anorectal inhibitory reflex and of anorectal sensitivity. Using this protocol it is possible to perform manometry in less than 30 minutes and to define the importance of anorectal function with approximately 10 parameters which are easily identified and interpreted

Calibrated lateral internal sphincterotomy for chronic anal fissure.

Lateral internal sphincterotomy is an effective procedure for the treatment of anal fissure, but may affected anal continence. We describe a procedure aimed at tailoring the division of the sphincter according to the degree of the hypertonia and to the sphincter length in order to offer an effective and safe treatment for chronic anal fissure. METHODS: The internal sphincter was divided on the basis of anal manometry results. The average of maximum values of resting pressure determined by the stationary motility protocol was considered the reference parameter to measure hypertonia. Mild hypertone was considered to be 50-60 mmHg, moderate hypertone 60-80 mmHg, and severe hypertone >80 mmHg. In case of mild hypertone, 20% of the internal sphincter was divided; in case of moderate hypertone; 40% and 60% for severe hypertone. Calibrated lateral internal sphincterotomy is the division of the internal sphincter based on these parameters. Over 5 years, 388 patients underwent this procedure (197 men, 191 women) with a median age of 43 years (range, 18-80). RESULTS: Postoperative complications consisted of abscess in 4 patients (1.0%), hemorrhage in 2 patients (0.5%), and pain in 6 patients (1.5%). Follow-up data are available for 261 patients (67.3%). Two months after surgery, 9 patients (3.4%) complained of persistent or recurring pain with or without fissure and 1 (0.4%) complained of gas incontinence. At postoperative manometry, 12 patients (4.6%) revealed persistence of anal resting pressure over 40 mmHg, 9 patients (3.4%) were still symptomatic and 97.6% were cured at a median follow-up of 8 months. An anal resting pressure lower than 30 mmHg was found in 10 patients (3.8%), only one of whom was incontinent. CONCLUSIONS: Calibrated sphincterotomy may represent an effective and safe procedure for the treatment of chronic anal fissure