Influence of prophylactic probiotics and selective decontamination on bacterial translocation in patients undergoing pancreatic surgery: a randomized controlled trial

Bacterial translocation (BT) is suspected to play a major role in the development of infections in surgical patients. However, the clinical association between intestinal barrier dysfunction, BT, and septic morbidity has remained unconfirmed. The objective of this study was to study BT in patients undergoing major abdominal surgery and the effects of probiotics, selective decontamination of the digestive tract (SDD), and standard treatment on intestinal barrier function. In a randomized controlled setting, 30 consecutive patients planned for elective pylorus-preserving pancreaticoduodenectomy (PPPD) were allocated to receive perioperatively probiotics, SDD, or standard treatment. To assess intestinal barrier function, intestinal fatty acid-binding protein (mucosal damage) and polyethylene glycol recovery (intestinal permeability) in urine were measured perioperatively. BT was assessed by real-time polymerase chain reaction and multiplex ligation-dependent probe amplification (MLPA) in mesenteric lymph nodes (MLNs) harvested early (baseline control) and at the end of surgery ("end-of-surgery" MLNs, after 3h in PPPD patients). Polymerase chain reaction detected bacterial DNA in 18 of 27 end-of-surgery MLNs and in 13 of 23 control MLNs (P = 0.378). Probiotics and SDD had no significant effect on the number of positive MLNs or the change in bacterial DNA during operation. Multiplex ligation-dependent probe amplification analysis showed significantly increased expression of only 4 of 30 inflammatory mediator-related genes in end-of-surgery compared with early sampled MLN (P < 0.05). Polyethylene glycol recovery was unaffected by operation, probiotics and SDD as compared with standard treatment. Intestinal fatty acid-binding protein levels were increased shortly postoperatively only in patients treated with SDD (P = 0.02). Probiotics and SDD did not influence BT, intestinal permeability, or inflammatory mediator expression. Bacterial translocation after abdominal surgery may be part of normal antigen-sampling processes of the gut.

Effects of adjustable gastric banding on gastroesophageal reflux and esophageal motility: a systematic review

Controversial opinions exist concerning the effect of laparoscopic adjustable gastric banding on gastroesophageal reflux. MEDLINE and EMBASE databases were searched for relevant studies on patients undergoing adjustable gastric banding. Data are expressed in mean (range). Twenty studies were identified with a total of 3307 patients. The prevalence of reflux symptoms decreased postoperatively from 32.9% (16-57) to 7.7% (0-26.9) and medication use from 27.5% (16-38.5) to 9.5% (3.1-19.2). Newly developed reflux symptoms were found in 15% (6.1-20) of the patients. The percentage of esophagitis decreased postoperatively from 33.3% (19.4-61.6) to 27% (2.3-60.8). Newly developed esophagitis was observed in 22.9% (0-38.4). Pathological reflux was found in 55.8% (34.9-77.4) preoperatively and postoperatively in 29.4% (0-41.7) of the patients. Lower esophageal sphincter pressures increased from 12.9 to 16.9 mmHg (11.3-21.4). Lower esophageal sphincter relaxation decreased from 100% to 79.7% (58-86). The percentage of dysmotility increased from 3.5% (0-10) to 12.6% (0-25). Adjustable gastric banding has anti-reflux properties resulting in resolution or improvement of reflux symptoms, normalized pH monitoring results and a decrease of esophagitis on short term. However, worsening or newly developed reflux symptoms and esophagitis are found in a subset of patients during longer follow-up.

Prevention, detection, and management of infected necrosis in severe acute pancreatitis

The management of infected peripancreatic or pancreatic necrosis in patients with severe pancreatitis has changed considerably in recent years. This review discusses the recent literature on prevention, detection, and management of infected necrosis. Though antibiotics, probiotics, and enteral nutrition have been tried to prevent infected necrosis, only enteral nutrition has consistently proven to be effective. Antibiotics and probiotics have not shown a consistent beneficial effect on outcome. Enteral nutrition reduced infectious complications and mortality in severe pancreatitis, compared with parenteral nutrition. The detection of infection of pancreatic necrosis is important for clinical decision making. Fine-needle aspiration may be used to confirm suspected infection, but if its results will not change clinical decisions, it should be omitted, as it may even introduce infection. Minimally invasive surgical, radiologic, or endoscopic intervention is increasingly being applied. In the absence of level 1 evidence, local expertise dictates which type of intervention is applied.

Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials

OBJECTIVE

To compare the effect of enteral vs parenteral nutrition in patients with severe acute pancreatitis for clinically relevant outcomes.

DATA SOURCES

A computerized literature search was performed in the MEDLINE, EMBASE, and Cochrane databases for articles published from January 1, 1966, until December 15, 2006.

STUDY SELECTION

From 253 publications screened, 5 randomized controlled trials comparing enteral and parenteral nutrition in patients with predicted severe acute pancreatitis met the inclusion criteria.

DATA EXTRACTION

Information on study design, patient characteristics, and acute pancreatitis outcomes were independently extracted by two of us using a standardized protocol.

DATA SYNTHESIS

A meta-analysis of randomized controlled trials was performed using a random-effects model. Enteral feeding reduced the risk of infectious complications (relative risk, 0.47; 95% confidence interval, 0.28-0.77; P < .001), pancreatic infections (0.48; 0.26-0.91; P = .02), and mortality (0.32; 0.11-0.98; P = .03). The risk reduction for organ failure was not statistically significant (0.67; 0.30-1.52; P = .34).

CONCLUSIONS

Enteral nutrition results in clinically relevant and statistically significant risk reduction for infectious complications, pancreatic infections, and mortality in patients with predicted severe acute pancreatitis.

[Obtaining medical ethical approval for a multicentre, randomised study: prospective evaluation of a ponderous process]

OBJECTIVE

To evaluate the procedure to obtain medical ethical approval for a multicentre study in the Netherlands.

DESIGN

Prospective and descriptive.

METHOD

The application procedure for medical ethical approval of a nationwide randomised multicentre trial (the 'Pancreatitis: surgical necrosectomy versus step up approach' (PANTER)-trial) from the ethics committees (EC) of 9 Dutch hospitals during 2004-2007, was prospectively evaluated. Several predefined variables regarding the duration of the ethical review process, the time invested and material and the type of queries raised by the ECs in all centres were collected.

RESULTS

Primary approval by the central EC of the coordinating hospital was obtained after 192 days. The duration of the review process for each of the 18 local participating centres was 105 days (range: 35-361). The maximum review term of 30 days, as defined in the national guideline, was reached by only one centre. It took two years to obtain approval for all participating centres. A median of 14 different documents (range: 5-23) were submitted to the EC of each participating centre. A total of 8314 A4 size papers (about 42 kg) were sent by post, 172 telephone calls were made and 136 e-mail messages were sent by the research fellow coordinating the application procedure. Of the local ECs in the participating centers, 95% requested additional revision of the patient information sheet and 78% requested changes in the informed consent form.

CONCLUSION

Obtaining medical ethical approval for this multicentre trial in the Netherlands was a long and inefficient process, requiring a considerable investment of time and resources. Streamlining the application procedure may lead to a substantial reduction in the current unnecessary delay of starting a multicentre study.

EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis

BACKGROUND

Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy.

METHODS

Retrospective cohort study on EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis.

RESULTS

8 patients (age 38-75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17-62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopic drainage was successful in all patients, a median of 4 (range 2-6) subsequent endoscopic necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopic drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8-60 months). One patient died.

CONCLUSION

EUS-guided endoscopic transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current 'gold standard' is warranted to determine the place of this treatment modality.

[Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial]

OBJECTIVE

To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications.

DESIGN

Multicentre, randomised, double-blind, placebo-controlled trial.

METHOD

A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949.

RESULTS

Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004).

CONCLUSION

In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones

BACKGROUND

According to the literature, the conversion rate for laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for cholecystodocholithiasis reaches 20%, at least when LC is performed 6 to 8 weeks afterward. It is hypothesized that early planned LC after ES prevents recurrent biliary complications and reduces operative morbidity and hospital stay.

METHODS

All consecutive patients who underwent LC after ES between 2001 and 2004 were retrospectively evaluated. Recurrent biliary complications during the waiting time for LC, conversion rate, postoperative complications, and hospital stay were documented.

RESULTS

This study analyzed 167 consecutive patients (59 men) with a median age of 54 years. The median interval between ES and LC was 7 weeks (range, 1-49 weeks). During the waiting time for LC, 33 patients (20%) had recurrent biliary complications including cholecystitis (n = 18, 11%), recurrent choledocholithiasis (n = 9, 5%), cholangitis (n = 4, 2%), and biliary pancreatitis (n = 2, 1%). Of these 33 patients, 15 underwent a second endoscopic retrograde cholangiography (ERC). The median time between ES and the development of recurrent complications was 22 days (range, 3-225 days). Most of the biliary complications (76%) occurred more than 1 week after ES. Conversion to open cholecystectomy occurred for 7 of 33 patients with recurrent complications during the waiting period, compared with 13 of 134 patients with an uncomplicated waiting period (p = 0.14). This concurred with doubled postoperative morbidity (24% vs 11%; p = 0.09) and a longer hospital stay (median, 4 vs 2 days; p < 0.001).

CONCLUSION

In this retrospective analysis, 20% of all patients had recurrent biliary complications during the waiting period for cholecystectomy after ES. These recurrent complications were associated with a significantly longer hospital stay. Cholecystectomy within 1 week after ES may prevent recurrent biliary complications in the majority of cases and reduce the postoperative hospital stay.

Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features

Imaging of patients with acute pancreatitis requires an understanding of the subtypes and complications that were defined at the Atlanta symposium in 1992. In the last decade, several new entities have been recognized with important clinical implications. In this article, the radiological aspects of the terminology and classification of acute pancreatitis are reviewed and new entities are clarified. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed and the limitations of each imaging technique, when interpreting pancreatic and peripancreatic inflammatory disease, are addressed.

Timing of surgical intervention in necrotizing pancreatitis

OBJECTIVE

To determine the effect of timing of surgical intervention for necrotizing pancreatitis.

DESIGN

Retrospective study of 53 patients and a systematic review.

SETTING

A tertiary referral center. Main Outcome Measure Mortality.

RESULTS

Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients from day 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (P < .001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P = .02). The 30-day group also had the lowest mortality (8% vs 75% in the 1 to 14-days group and 45% in the 15 to 29-days group, P < .001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P = .09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing of surgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R = - 0.603; 95% confidence interval, - 2.10 to - 0.02; P = .05).

CONCLUSION

Postponing necrosectomy until 30 days after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, and increased incidence of Candida species and antibiotic-resistant organisms.

Antimicrobial activity of a multispecies probiotic (Ecologic 641) against pathogens isolated from infected pancreatic necrosis

AIMS

Although probiotic prophylaxis has been suggested to prevent small bowel bacterial overgrowth, bacterial translocation and infection of pancreatic necrosis in severe acute pancreatitis, limited data are available on their antimicrobial activity.

METHODS AND RESULTS

Using the well-diffusion method, we studied the antimicrobial properties of a multispecies probiotic product (Ecologic 641) against a collection of pathogens cultured from infected pancreatic necrosis. All individual probiotic strains included in the multispecies preparation were able to inhibit the growth of the pathogens to some extent. However, the combination of the individual strains (i.e. the multispecies preparation) was able to inhibit all pathogenic isolates. Probiotic-free supernatants adjusted to pH 7 were not able to inhibit pathogen growth.

CONCLUSION

Ecologic 641 is capable of inhibiting growth of a wide variety of pathogens isolated from infected pancreatic necrosis. The antimicrobial properties are to a large extent explained by the production of organic acids.

SIGNIFICANCE AND IMPACT OF THE STUDY

Ecologic 641 is currently being used in a Dutch nationwide double-blind, placebo-controlled, randomized multicentre trial in patients with predicted severe acute pancreatitis.

Randomized controlled trials of antibiotic prophylaxis in severe acute pancreatitis: relationship between methodological quality and outcome

AIM

To evaluate the methodological quality of randomized controlled trials (RCTs) of systemic antibiotic prophylaxis in severe acute pancreatitis in relation to outcome.

METHODS

The MEDLINE, EMBASE and Cochrane databases were searched for RCTs that studied the effectiveness of systemic antibiotic prophylaxis in severe acute pancreatitis. A meta-analysis was performed with a random effects model. Methodological quality was quantified by a previously published scoring system (range 0-17 points).

RESULTS

Six studies, with a total of 397 participants, obtained a methodological score of at least 5 points and were included. Systemic antibiotic prophylaxis had no significant effect on infection of pancreatic necrosis (absolute risk reduction (ARR) 0.055; 95% CI -0.084 to 0.194) and mortality (ARR 0.058, 95% CI -0.017 to 0.134). Spearman correlation showed an inverse association between methodological quality and ARR for mortality (correlation coefficient -0.841, p = 0.036).

CONCLUSIONS

The inverse relationship between methodological quality and impact of antibiotic prophylaxis on mortality emphasizes the importance of high-quality RCTs. At present, adequate evidence for the routine use of antibiotic prophylaxis in severe acute pancreatitis is lacking.

Oral refeeding after onset of acute pancreatitis: a review of literature

BACKGROUND

Oral refeeding in patients recovering from acute pancreatitis may cause pain relapse. Patients with pain relapse may be ill for prolonged periods, thereby consuming additional health care resources. We aimed to determine the incidence and risk factors of pain relapse on the basis of reviewing all studies on oral refeeding in acute pancreatitis.

METHODS

Relevant literature cited in three electronic databases (Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE) as well as the abstracts of major gastroenterological meetings was reviewed. Outcome measures studied were the incidence of pain relapse and length of hospital stay.

RESULTS

A total of three studies met the inclusion criteria. Sixty of 274 patients (21.9%) experienced pain relapse during the course of acute pancreatitis. In 47 of 60 (78.3%) patients pain relapse occurred within 48 h after commencement of oral refeeding. Two studies showed a significantly higher Balthazar's CT score on hospital admission in patients with pain relapse, whereas all three studies found no difference in the severity scores between patients with and without pain relapse. All three studies found a significant increase in the length of hospital stay in patients with pain relapse.

CONCLUSIONS

The incidence of pain relapse after oral refeeding in acute pancreatitis is relatively high. Thereby, the quest for new therapeutical modalities that can prevent pain relapse is of current importance.

Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms

OBJECTIVES

The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium.

METHODS

We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis."

RESULTS

A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis."

CONCLUSIONS

This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.

Intense adrenal enhancement in patients with acute pancreatitis and early organ failure

Intense adrenal enhancement has previously been reported in patients with hypovolemic and septic shock. The purpose of this study was to assess whether this computed tomography (CT) finding is also observed in patients presenting with severe acute pancreatitis and early organ failure. A retrospective analysis of a prospectively collected database was performed. Out of 38 consecutive patients with predicted severe acute pancreatitis, 3 patients showed intense bilateral adrenal enhancement on early CT. All patients had early multiple organ failure and subsequently died. In two cases, pathologic correlation was obtained. Intense adrenal enhancement may be a new prognostic indicator in patients with acute pancreatitis, particularly when organ failure is present at the time of CT examination. Further studies are necessary to confirm this observation.

Management of severe acute pancreatitis: it's all about timing

PURPOSE OF REVIEW

This study provides an update on the treatment of severe acute pancreatitis (SAP) with emphasis on nutrition, infection-prophylaxis, biliary pancreatitis, surgical intervention and new randomized controlled trials.

RECENT FINDINGS

The most relevant new insights are: (i) early enteral nutrition in SAP is not only capable of reducing infectious complications but may also reduce mortality; (ii) there is increasing evidence that antibiotic-prophylaxis is not capable of preventing infectious complications in SAP; (iii) probiotic-prophylaxis is being considered as an alternative with promising experimental results; (iv) in biliary pancreatitis, early endoscopic retrograde cholangiography with sphincterotomy (within 48 h) is beneficial in case of ampullary obstruction, although it may be withheld in the event of negative endoscopic ultrasound; (v) surgical intervention for infected (peri-)pancreatic necrosis is increasingly being postponed; (vi) minimally invasive strategies are being considered as a full alternative for necrosectomy by laparotomy in infected (peri-)pancreatic necrosis; (vii) the Atlanta classification should no longer be used to describe computed tomography findings in acute pancreatitis; and (viii) only five randomized controlled trials of patients with acute pancreatitis are currently registered in the international trial registries.

SUMMARY

Timing of intervention is becoming increasingly important in SAP management.

[Symptomatic gallstone disease: an indication for surgery]

Three patients, men in the ages of 58, 66 and 56 years, respectively, had experienced 'warning colics' a considerable time before gallstone complications or severe recurrent colic. Ultrasonographically proven gallstones had not led to cholecystectomy. The 58-year-old man died of sepsis due to infected pancreatic necrosis; the other men underwent laparoscopic cholecystectomy, after which they recovered fully. Approximately 10-5% of the adult Dutch population have gallstones, but only 10% will develop symptoms. The annual risk for developing complicated gallstone disease is 1-2% in asymptomatic gallstone carriers. Of patients admitted with complicated gallstone disease, 58% have had prior 'warning colics'. Complicated gallstone disease can be prevented by timely treatment after recognition of warning colics. Cholecystectomy is indicated in patients with intermittent upper-abdominal pain and proven gallstones or sludge.

Describing computed tomography findings in acute necrotizing pancreatitis with the Atlanta classification: an interobserver agreement study

OBJECTIVES

The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. A study was undertaken to assess the interobserver agreement of categorizing peripancreatic collections on computed tomography (CT) using the Atlanta classification.

METHODS

Preoperative contrast-enhanced CTs from 70 consecutive patients (49 men; median age, 59 years; range, 29-79 years) operated for acute necrotizing pancreatitis (2000-2003) in 11 hospitals were reviewed. Five abdominal radiologists independently categorized the peripancreatic collections according to the Atlanta classification. Radiologists were aware of the timing of the CT and the clinical condition of the patient. Interobserver agreement was determined.

RESULTS

Interobserver agreement among the radiologists was poor (kappa, 0.144; SD, 0.095). In 3 (4%) of 70 cases, the same Atlanta definition was chosen. In 13 (19%) of 70 cases, 4 radiologists agreed, and in 42 (60%) of 70 cases, 3 radiologists agreed on the definition. In 21 cases (30%), 1 or more of the radiologists classified a collection as "pancreatic abscess," whereas 1 or more radiologist used another Atlanta definition.

CONCLUSION

The interobserver agreement of the Atlanta classification for categorizing peripancreatic collections in acute pancreatitis on CT is poor. The Atlanta classification should not be used to describe complications of acute pancreatitis on CT.

[A nationwide Dutch study into the optimal treatment of patients with infected necrotising pancreatitis: the PANTER trial]

Surgical intervention in infected necrotising pancreatitis generally consists of necrosectomy via laparotomy. The morbidity and mortality after this procedure might be reduced by minimally invasive strategies. The 20 hospitals of the Dutch Acute Pancreatitis Study Group are currently enrolling patients in a randomised trial to compare (a) laparotomy with necrosectomy and continuous postoperative lavage with (b) CT-guided or endoscopic transgastric drainage, if necessary, followed by videoscopic assisted retroperitoneal debridement (VARD): the PANTER trial ('pancreatitis, necrosectomy versus a minimally invasive step-up approach'). The primary endpoint is the proportion of patients suffering from major postoperative morbidity and mortality. Patients with (suspected) infected necrotising pancreatitis can be put forward for participation in the trial in one of the 20 participating centres.

Ursodeoxycholic acid exerts no beneficial effect in patients with symptomatic gallstones awaiting cholecystectomy

Ursodeoxycholic acid (UDCA) and impaired gallbladder motility purportedly reduce biliary pain and acute cholecystitis in patients with gallstones. However, the effect of UDCA in this setting has not been studied prospectively. This issue is important, as in several countries (including the Netherlands) scheduling problems result in long waiting periods for elective cholecystectomy. We conducted a randomized, double-blind, placebo-controlled trial on effects of UDCA in 177 highly symptomatic patients with gallstones scheduled for cholecystectomy. Patients were stratified for colic number in the preceding year (<3: 32 patients; > or =3: 145 patients). Baseline postprandial gallbladder motility was measured by ultrasound in 126 consenting patients. Twenty-three patients (26%) receiving UDCA and 29 (33%) receiving placebo remained colic-free during the waiting period (89 +/- 4; median [range]: 75[4-365] days) before cholecystectomy (P = .3). Number of colics, non-severe biliary pain, and analgesics intake were comparable. A low number of prior colics was associated with a higher likelihood of remaining colic-free (59% vs. 23%, P < .001), without effects on the risk of complications. In patients evaluated for gallbladder motility, 57% were weak and 43% were strong contractors (minimal gallbladder volume > respectively < or = 6 mL). Likelihood to remain colic-free was comparable in strong and weak contractors (31% vs. 33%). In weak contractors, UDCA decreased likelihood to remain colic-free (21% vs. 47%, P = .02). In the placebo group, 3 preoperative and 2 post-cholecystectomy complications occurred. In contrast, all 4 complications in the UDCA group occurred after cholecystectomy. In conclusion, UDCA does not reduce biliary symptoms in highly symptomatic patients. Early cholecystectomy is warranted in patients with symptomatic gallstones.

[Potential role for probiotics in the prevention of infectious complications during acute pancreatitis]

Acute pancreatitis has a high mortality in case of secondary infection of (peri-)pancreatic necrosis. Bacterial translocation is held responsible for the majority of these infectious complications of severe acute pancreatitis. Prophylactic strategies should therefore be directed at the three most important pathophysiological mechanisms of bacterial translocation: disturbed small-bowel motility and bacterial overgrowth, failure of the mucosal barrier function and a disturbed response of the immune system. In-vitro studies and research in experimental animals have shown that specially selected probiotics exert an effect on these mechanisms and can prevent bacterial translocation. Recently, several randomised, double-blind, placebo-controlled trials evaluating prophylactic treatment with enteral probiotics have shown good results. A Dutch multicentre trial, 'Probiotics in pancreatitis trial' (PROPATRIA), is currently underway.

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES

Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy.

METHODS

Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations.

RESULTS

Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (<or=5 mm) gallstones (5,000 patients, 67% females, 45 yr old, 10-yr follow-up) indicates that life-years may be gained or lost by cholecystectomy, depending on incidence and mortality of pancreatitis.

CONCLUSIONS

Small gallstones are associated with pancreatitis. Prophylactic cholecystectomy may lead to gain or loss of life-years in patients with small stones, depending on incidence and mortality of pancreatitis.

Prevention of infectious complications in surgical patients: potential role of probiotics

Infectious complications in surgical patients often originate from the intestinal microflora. In the critically ill patient, small bowel motility is disturbed, leading to bacterial overgrowth and subsequent bacterial translocation due to dysfunction of the gut mucosal barrier. The optimal prophylactic strategy should act on all these factors, but such a strategy is not yet available. For several decades, antibiotic prophylaxis to prevent translocation of pathogenic bacteria has been studied with conflicting results. Selective decontamination of the digestive tract has shown good results, but fear for bacterial multiresistance has prevented worldwide implementation. In recent years, probiotics, living bacteria with a potential beneficial effect to their host, have shown promising results in several randomized placebo-controlled trials. Currently, in vitro and experimental research focuses on the effects of probiotics on the microflora responsible for gut-derived infections, structural mucosal barrier function and the immune system.

[Timing and choice of intervention in necrotising pancreatitis]

Three patients, men aged 49, 62 and 33 years, were admitted with acute abdominal symptoms due to necrotising pancreatitis. They underwent multiple interventions during a hospital stay of several months, but ultimately recovered completely. In case of infected (peri-)pancreatic necrosis, intervention is required. Good clinical judgement in the differentiation between the septic inflammatory-response syndrome, sepsis and infected necrosis as the cause of the clinical condition is important. Because of the different intervention strategies, treatment by a team comprising a radiologist, gastroenterologist, intensive care specialist and gastrointestinal surgeon is required. Randomised studies on intervention in infected pancreatic necrosis are lacking. In 2002, to improve the treatment of patients with acute (necrotising) pancreatitis via a combination of research, consultation and centralisation, the Dutch Acute Pancreatitis Study Group was formed.

Beneficial effects of ERCP and papillotomy in predicted severe biliary pancreatitis

BACKGROUND/AIMS

Extensive circumstantial evidence indicates that patients with a predicted severe attack of acute biliary pancreatitis (ABP) should undergo an endoscopic retrograde cholangiography with papillotomy (ERC/PT). However, in clinical practice this procedure is not always performed. This study was conducted to compare outcome in patients with and without ERC/PT.

METHODOLOGY

Thirty-five of 80 patients admitted with ABP had a predicted severe attack (three or more Ranson criteria). Only in 24 of these 35 patients was an ERC/PT performed.

RESULTS

In the ERC/PT group, significantly less pancreatic necrosis (8 vs. 64%, p<0.001) occurred, hospital stay was shorter (median 22 +/- 5 vs. 51 +/- 19 days, P=0.08) and mortality was lower (8 vs. 36%, P=0.01). Twenty-three patients (66%) underwent cholecystectomy after a median period of 10 weeks (range 0-26 weeks) after discharge. During the waiting period, in the ERC/PT group, two patients developed acute cholecystitis whereas recurrent ABP and common bile duct stones occurred in one patient each.

CONCLUSIONS

In patients with a predicted severe attack of ABP, performing ERC/PT is associated with less morbidity and lower mortality.

Colonic involvement in acute pancreatitis. A retrospective study of 16 patients

BACKGROUND

Diagnosis of colonic pathology complicating acute pancreatitis is difficult. Several pathogenetic mechanisms have been proposed. The treatment of choice is resection of the affected segment. Current theories on diagnosis, pathogenesis, and treatment were reviewed.

METHOD

Retrospectively, 16 patients with severe acute pancreatitis and colonic complications (1988-2001) were included. Preoperative CT scans and specimens of removed colonic segments were reviewed by a blinded radiologist and pathologist respectively.

RESULTS

Sixteen patients underwent partial colectomy for suspected imminent or overt perforation, based on the outer aspect of the colon. Four patients had a macroscopic perforation during surgery. Retroperitoneal spread of the necrotizing process to the colon was seen in all 10 reviewed CT scans. All 14 microscopically examined specimens showed fat necrosis and pericolitis. Of these, 4 had ischemia and 6 showed subserosal hemorrhage. Eight specimens had intact mucosa, submucosa and smooth muscle layers. Eleven patients died. Secondary anastomosis in surviving patients did not induce further mortality.

CONCLUSION

Spread of pancreatic enzymes and necrosis is the major cause for colonic pathology in acute pancreatitis. Outside inspection of the colon during surgery is unreliable to detect ischemia or imminent perforation. To prevent colonic complications during follow-up, low-threshold colonic resection seems justified.

Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review

BACKGROUND

The course of acute pancreatitis (AP) is unpredictable and can vary from mild to lethal. Mortality varies from low (<2%) in mild cases to high (20%-70%) in the case of infected pancreatic necrosis. Surgical management has not been investigated in well-designed trials. Based on literature review and retrospective results from our institution, recent insights are summarized and recommendations concerning surgical treatment of AP are given.

METHODS

Data of patients who underwent necrosectomy for AP in our hospital in the period 1988-2001 were reviewed. Surgical treatment strategy was divided into open abdomen strategy (OAS) and primary closure with continuous postoperative lavage (CPL). An extensive database literature search was performed to obtain articles on surgical management of AP. Level 5 evidence articles were excluded.

RESULTS

In our institution, 38 patients were treated with OAS and 21 with CPL. Mortality was high (47% in the OAS group and 33% in the CPL group). The primary cause of mortality was multiorgan failure. Only 50 manuscripts from the literature search contained useful data. Mortality of patients with OAS and CPL treatment was 27% and 15%. respectively. Fewer cases of gastro-intestinal fistulas. bleeding and re-interventions were reported with CPL. The majority of all survivors regained a good quality of life.

CONCLUSION

Mortality of acute necrotizing pancreatitis remains high, despite optimal surgical and medical treatment. Current surgical practice is not based on well-designed clinical trails. Randomized studies are needed to define evidence-based surgery in acute necrotizing pancreatitis.

Long-term results after laparoscopic Thal procedure in children

As the laparoscopic approach to gastroesophageal reflux disease (GERD) was introduced in pediatric surgery in the last decade of the 20th century, it became apparent that this approach was beneficial. The favorable results have led to a more general acceptance and implementation of this type of surgery at the beginning of the 21st century. We give an overview of the first decade of laparoscopic antireflux procedures in children with an emphasis on the laparoscopic Thal fundoplication and its implication on morbidity and cure of GERD in the long term both for normal and mentally handicapped children. Between 1993 and 2002, 149 children with GERD underwent 157 laparoscopic antireflux procedures, of whom 48% were mentally handicapped. Follow-up ranged from 6 months to 9 years (median age 4.5 years). Nineteen children died. All but one were not related to the antireflux procedure. Immediate relief of symptoms occurred in 120 children (80.5%). In 29 children, the results were less than optimal. Eight patients underwent a laparoscopic redo procedure (5.4%). However, none of the children with a follow-up of more than 5 years show any symptoms anymore. In conclusion, the laparoscopic Thal fundoplication is a safe procedure, and results in the long term are favorable, irrespective of the nature of the cause, ie, mental retardation.

Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review

BACKGROUND

The course of acute pancreatitis (AP) is unpredictable and can vary from mild to lethal. Mortality varies from low (<2%) in mild cases to high (20%-70%) in the case of infected pancreatic necrosis. Surgical management has not been investigated in well-designed trials. Based on literature review and retrospective results from our institution, recent insights are summarized and recommendations concerning surgical treatment of AP are given.

METHODS

Data of patients who underwent necrosectomy for AP in our hospital in the period 1988-2001 were reviewed. Surgical treatment strategy was divided into open abdomen strategy (OAS) and primary closure with continuous postoperative lavage (CPL). An extensive database literature search was performed to obtain articles on surgical management of AP. Level 5 evidence articles were excluded.

RESULTS

In our institution, 38 patients were treated with OAS and 21 with CPL. Mortality was high (47% in the OAS group and 33% in the CPL group). The primary cause of mortality was multiorgan failure. Only 50 manuscripts from the literature search contained useful data. Mortality of patients with OAS and CPL treatment was 27% and 15%. respectively. Fewer cases of gastro-intestinal fistulas. bleeding and re-interventions were reported with CPL. The majority of all survivors regained a good quality of life.

CONCLUSION

Mortality of acute necrotizing pancreatitis remains high, despite optimal surgical and medical treatment. Current surgical practice is not based on well-designed clinical trails. Randomized studies are needed to define evidence-based surgery in acute necrotizing pancreatitis.

Long-term results after laparoscopic Thal procedure in children

As the laparoscopic approach to gastroesophageal reflux disease (GERD) was introduced in pediatric surgery in the last decade of the 20th century, it became apparent that this approach was beneficial. The favorable results have led to a more general acceptance and implementation of this type of surgery at the beginning of the 21st century. We give an overview of the first decade of laparoscopic antireflux procedures in children with an emphasis on the laparoscopic Thal fundoplication and its implication on morbidity and cure of GERD in the long term both for normal and mentally handicapped children. Between 1993 and 2002, 149 children with GERD underwent 157 laparoscopic antireflux procedures, of whom 48% were mentally handicapped. Follow-up ranged from 6 months to 9 years (median age 4.5 years). Nineteen children died. All but one were not related to the antireflux procedure. Immediate relief of symptoms occurred in 120 children (80.5%). In 29 children, the results were less than optimal. Eight patients underwent a laparoscopic redo procedure (5.4%). However, none of the children with a follow-up of more than 5 years show any symptoms anymore. In conclusion, the laparoscopic Thal fundoplication is a safe procedure, and results in the long term are favorable, irrespective of the nature of the cause, ie, mental retardation.