Subtotal pancreatectomy for cancer: closure of the pancreatic remnant with staplers

This paper presents a 2-year series of 26 consecutive pancreatectomies for periampullary cancer where the pancreatic tail was closed with a stapler in order to avoid complications related to a pancreatico-digestive anastomosis. The follow-up period was 14 months or more. Seven patients developed operative complications. Pancreatic fistulas developed in 3 patients. The fistulas closed spontaneously in 2 of the patients after 2-4 months. Intraabdominal abscesses developed in 4 patients and required surgical drainage. In 1 of these patients, the abscess eroded a large vessel with a fatal outcome resulting in an operative mortality rate of 3.8%. A transient postoperative gastric stasis was observed in seven patients. Postoperative hospital median stay was 27 days (range 10-83 days). Eighteen patients have died after 4-30 months in recurrent disease and seven patients are alive after a follow-up period of 15-29 months. Pancreatic endocrine function seemed well preserved; diabetes mellitus has developed in only one patient. In conclusion, it appears that subtotal pancreatectomy with closure of the pancreatic remnant with staples gives a low morbidity and mortality. Although the conclusion should be tempered by the small number of patients, the results justify continued evaluation of this technique with long-term follow-up

The role of octreotide in preventing complications after pancreatoduodenectomy for cancer

Background Although the mortality rate of pancreatoduodenectomy has fallen sharply over the last two decades, there is still a risk of serious complications resulting from leakage at the site of anastomosis between the pancreatic remnant and the gastrointestinal tract. Numerous techniques have been described to minimise the risk of these anastomotic leaks, but they can be difficult to avoid if the distal pancreas is unobstructed with a soft parenchyma and a non-dilated duct. The risk of leakage is largely dependent upon the presence of activated pancreatic enzymes, and this fact provides a rationale for the perioperative use of the somatostatin analogue octreotide to inhibit exocrine pancreatic secretion. Discussion Six prospective randomised controlled trials have been published on the use of prophylactic octreotide in pancreatic surgery, five from Europe and one from the USA. The five (multicentre) European studies have consistently shown that octreotide reduces the postoperative complication rate, but the American study does not confirm this benefit. Methodological differences may explain the discrepancy, notably the fact that most of the US patients had received preoperative chemoradiation which is likely to have reduced enzyme secretion. A meta-analysis of four of these studies showed that octreotide lowered the rate of postoperative complications from 37 to 21%, chiefly by reducing the risk of pancreatic fistula. Prophylactic octreotide therapy is cost effective and should be used at least in patients with normal pancreatic parenchyma

Head injury triage in a sub Saharan African urban population

AbstractBackgroundInjuries are the ninth leading cause of death in the world and disproportionately affect low- and middle-income countries. Head injury is the leading cause of trauma death. This study examines the epidemiology and outcomes of traumatic head injury presenting to a tertiary hospital in Malawi, in order to determine effective triage in a resource limited setting.MethodsThe study was conducted at Kamuzu Central Hospital (KCH) in Lilongwe Malawi during a three-month period. Vital signs and Glasgow Coma Score (GCS) were prospectively collected for all patients that presented to the casualty department secondary to head injury. All head injury admissions were followed until death or discharge.ResultsDuring the three-month study period, 4411 patients presented to KCH secondary to trauma and 841 (19%) had a head injury. A multivariate logistic regression model revealed that GCS and heart rate changes correlated strongly with mortality. There is a four-fold increase in the odds of mortality in moderate versus mild head injury based on GCS.ConclusionIn a resource limited setting, basic trauma tools such as GCS and heart rate can effectively triage head injury patients, who comprise the most critically ill trauma patients. Improvements in head injury outcome require multifaceted efforts including the development of a trauma system to improve pre-hospital care

The Role of Bile in the Regulation of Exocrine Pancreatic Secretion

As early as 1926 Mellanby (1) was able to show that introduction of bile into the duodenum of anesthetized cats produces a copious flow of pancreatic juice. In conscious dogs, Ivy & Lueth (2) reported, bile is only a weak stimulant of pancreatic secretion. Diversion of bile from the duodenum, however, did not influence pancreatic volume secretion stimulated by a meal (3,4). Moreover, Thomas & Crider (5) observed that bile not only failed to stimulate the secretion of pancreatic juice but also abolished the pancreatic response to intraduodenally administered peptone or soap