Toward a new paradigm of care: a surgical leaders' Delphi consensus on the organizational factors of the new pancreas units (E-AHPBA PUECOF study)

Pancreas units represent new organizational models of care that are now at the center of the European debate. The PUECOF study, endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), aims to reach an expert consensus by enquiring surgical leaders about the Pancreas Units' most relevant organizational factors, with 30 surgical leaders from 14 countries participating in the Delphi survey. Results underline that surgeons believe in the need to organize multidisciplinary meetings, nurture team leadership, and create metrics. Clinical professionals and patients are considered the most relevant stakeholders, while the debate is open when considering different subjects like industry leaders and patient associations. Non-technical skills such as ethics, teamwork, professionalism, and leadership are highly considered, with mentoring, clinical cases, and training as the most appreciated facilitating factors. Surgeons show trust in functional leaders, key performance indicators, and the facilitating role played by nurse navigators and case managers. Pancreas units have a high potential to improve patients' outcomes. While the pancreas unit model of care will not change the technical content of pancreatic surgery, it may bring surgeons several benefits, including more cases, professional development, easier coordination, less stress, and opportunities to create fruitful connections with research institutions and industry leaders.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Discharge protocol in acute pancreatitis: an international survey and cohort analysis

There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients' care.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Hypophosphatemia as a prognostic tool for post-hepatectomy liver failure: A systematic review

BACKGROUND

Post-hepatectomy liver failure (PHLF) is one of the main causes of postoperative mortality and is challenging to predict early in patients after liver resection. Some studies suggest that the postoperative serum phosphorus might predict outcomes in these patients.

AIM

To perform a systematic literature review on hypophosphatemia and evaluate it as a prognostic factor for PHLF and overall morbidity.

METHODS

This systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses statement. A study protocol for the review was registered in the International Prospective Register of Systematic Reviews database. PubMed, Cochrane and Lippincott Williams & Wilkins databases were systematically searched up to March 31, 2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for PHLF, overall postoperative morbidity and liver regeneration. The quality assessment of the included cohort studies was performed according to the Newcastle-Ottawa Scale.

RESULTS

After final assessment, nine studies (eight retrospective and one prospective cohort study) with 1677 patients were included in the systematic review. All selected studies scored ≥ 6 points according to the Newcastle-Ottawa Scale. Cutoff values of hypophosphatemia varied from < 1 mg/dL to ≤ 2.5 mg/dL in selected studies with ≤ 2.5 mg/dL being the most used defining value. Five studies analyzed PHLF, while the remaining four analyzed overall complications as a main outcome associated with hypophosphatemia. Only two of the selected studies analyzed postoperative liver regeneration, with reported better postoperative liver regeneration in cases of postoperative hypophosphatemia. In three studies hypophosphatemia was associated with better postoperative outcomes, while six studies revealed hypophosphatemia as a predictive factor for worse patient outcomes.

CONCLUSION

Changes of the postoperative serum phosphorus level might be useful for predicting outcomes after liver resection. However, routine measurement of perioperative serum phosphorus levels remains questionable and should be evaluated individually.

DNA Methylation of HOXA11 Gene as Prognostic Molecular Marker in Human Gastric Adenocarcinoma

Hypermethylation of tumor suppressor genes and hypomethylation of oncogenes might be identified as possible biomarkers in gastric cancer (GC). We aimed to assess the DNA methylation status of selected genes in GC tissue samples and evaluate these genes’ prognostic importance on patient survival. Patients (99) diagnosed with GC and who underwent gastrectomy were included. We selected a group of genes (RAD51B, GFRA3, AKR7A3, HOXA11, TUSC3, FLI1, SEZ6L, GLDC, NDRG) which may be considered as potential tumor suppressor genes and oncogenes. Methylation of the HOXA11 gene promoter was significantly more frequent in GC tumor tissue (p = 0.006) than in healthy gastric mucosa. The probability of surviving longer (71.2 months (95% CI 57–85.3) vs. 44.3 months (95% CI 34.8–53.9)) was observed with unmethylated HOXA11 promoter in cancer tissues. Survival in patients with a methylation of HOXA11 promoter either in healthy gastric mucosa or gastric cancer tissue was twice as high as in patients with a methylation of HOXA11 promoter in both healthy gastric mucosa and cancer tissue (61.2 months (95% CI 50.9–71.4) vs. 28.5 months (95% CI 20.8–36.2)). Multivariate Cox analysis revealed the HOXA11 methylation as significantly associated with patients’ survival (HR = 2.4, 95% CI 1.19–4.86). Our results suggest that the HOXA11 gene might be a potential prognostic molecular marker in patients with gastric adenocarcinoma.

Structural imaging findings are related to clinical complications in chronic pancreatitis

BACKGROUND/OBJECTIVES

Structural pancreatic changes and complications related to chronic pancreatitis are well described, but little is known about their relationship. We aimed to explore the associations between pancreatic morphology and clinical complications in a large chronic pancreatitis cohort.

METHODS

The Scandinavian Baltic Pancreatic Club database collects registrations on patients with definite or probable chronic pancreatitis according to the M-ANNHEIM diagnostic criteria. In this cross-sectional study, we used multivariate logistic regression analyses to evaluate whether imaging-based structural pancreatic changes were associated with common clinical complications. We adjusted for sex, age, disease duration, current alcohol abuse and current smoking.

RESULTS

We included 742 patients with a mean age of 55 years. Among these, 68% were males, 69% had pancreatic exocrine insufficiency, 35% had diabetes, 12% were underweighted and 68% reported abdominal pain. Main pancreatic duct obstruction, severe (i.e. more than 14) calcifications, pancreatic atrophy and parenchymal changes throughout the entire pancreas (continuous organ involvement) were positively associated with pancreatic exocrine insufficiency. Continuous organ involvement and pseudocysts were positively and negatively associated with diabetes, respectively. Pancreatic atrophy and severe calcifications were positively associated with underweight, and severe calcifications were negatively associated with pain.

CONCLUSIONS

This study shows independent associations between distinct structural changes on pancreatic imaging and clinical complications in chronic pancreatitis. Pancreatic atrophy, severe calcifications and continuous organ involvement may be of particular clinical relevance, and these findings should motivate monitoring of pancreatic function and nutritional status.

Dynamic perfusion CT - A promising tool to diagnose pancreatic ductal adenocarcinoma

Background and objective

This study deals with an important issue of setting the role and value of the dynamic computed tomography (CT) perfusion analysis in diagnosing pancreatic ductal adenocarcinoma (PDAC). The study aimed to assess the efficacy of perfusion CT in identifying PDAC, even isodense or hardly depicted in conventional multidetector computed tomography.

Methods

A total of 56 patients with PDAC and 56 control group patients were evaluated in this study. A local perfusion assessment, involving the main perfusion parameters, was evaluated for all the patients. Sensitivity, specificity, positive, and negative predictive values for each perfusion CT parameter were defined using cutoff values calculated using receiver operating characteristic curve analysis. We accomplished logistic regression to identify the probability of PDAC.

Results

Blood flow (BF) and blood volume (BV) values were significant independent diagnostic criteria for the presence of PDAC. If both values exceed the determined cutoff point, the estimated probability for the presence of PDAC was 97.69%.

Conclusions

Basic CT perfusion parameters are valuable in providing the radiological diagnosis of PDAC. The estimated BF and BV parameters may serve as independent diagnostic criteria predicting the probability of PDAC.

Dynamic Perfusion Computed Tomography and Apparent Diffusion Coefficient as Potential Markers for Poorly Differentiated Pancreatic Adenocarcinoma

INTRODUCTION

Tumor grade, one of the most important risk factors for survival, is routinely determined after examining the biopsy material or a surgically removed specimen. The aim of the study was to analyze computed tomography (CT) perfusion parameters and diffusion-weighted imaging apparent diffusion coefficient (ADC) values in pancreatic ductal adenocarcinoma (PDAC) and to establish the diagnostic value of these modalities determining the tumor grade.

MATERIALS AND METHODS

A prospective clinical study included 56 subjects with PDAC. All the patients had a local perfusion assessment and ADC measurement of the tumor. For the prediction of poor tumor differentiation sensitivity, specificity, positive, and negative predictive values for each perfusion CT and ADC parameters based on cutoff values from ROC analysis were calculated.

RESULTS

Mean transit time (MTT) and ADC values were found to be independent prognosticators for the presence of G3 PDAC. MTT and ADC at the cutoff of 17.37 s and 1.15 × 10-3 mm2/s, respectively, appeared to be significant parameters discriminating against the differentiation grade of PDAC. If both values exceeded the defined cutoff point, the estimated probability for the presence of G3 PDAC was 89.29%.

CONCLUSION

The MTT parameter, calculated with the deconvolution method, and the ADC value may serve as effective independent prognosticators identifying poorly differentiated PDAC.

Acid suppression therapy, gastrointestinal bleeding and infection in acute pancreatitis - An international cohort study

BACKGROUND

Acid suppressing drugs (ASD) are generally used in acute pancreatitis (AP); however, large cohorts are not available to understand their efficiency and safety. Therefore, our aims were to evaluate the association between the administration of ASDs, the outcome of AP, the frequency of gastrointestinal (GI) bleeding and GI infection in patients with AP.

METHODS

We initiated an international survey and performed retrospective data analysis on AP patients hospitalized between January 2013 and December 2018.

RESULTS

Data of 17,422 adult patients with AP were collected from 59 centers of 23 countries. We found that 23.3% of patients received ASDs before and 86.6% during the course of AP. ASDs were prescribed to 57.6% of patients at discharge. ASD administration was associated with more severe AP and higher mortality. GI bleeding was reported in 4.7% of patients, and it was associated with pancreatitis severity, mortality and ASD therapy. Stool culture test was performed in 6.3% of the patients with 28.4% positive results. Clostridium difficile was the cause of GI infection in 60.5% of cases. Among the patients with GI infections, 28.9% received ASDs, whereas 24.1% were without any acid suppression treatment. GI infection was associated with more severe pancreatitis and higher mortality.

CONCLUSIONS

Although ASD therapy is widely used, it is unlikely to have beneficial effects either on the outcome of AP or on the prevention of GI bleeding during AP. Therefore, ASD therapy should be substantially decreased in the therapeutic management of AP.

Pain and aetiological risk factors determine quality of life in patients with chronic pancreatitis, but a brick in the puzzle is missing

BACKGROUND AND OBJECTIVES

Chronic pancreatitis (CP) is a debilitating fibro-inflammatory disease with a profound impact on patients' quality of life (QOL). We investigated determinants of QOL in a large cohort of CP patients.

METHODS

This was a multicentre study including 517 patients with CP. All patients fulfilled the EORTC QLQ-C30 questionnaire. Questionnaire responses were compared to results obtained from a general reference population (n = 11,343). Demographic characteristics, risk factors (smoking and alcohol consumption), pain symptoms, disease phenotype (complications) and treatments were recorded. A multivariable regression model was used to identify factors independently associated with QOL scores.

RESULTS

Included patients had a mean age of 56.3 ± 12.8 years, 355 (69%) were men and 309 (60%) had alcohol aetiology. Compared to the reference population, patients with CP had lower global health status (50.5 vs. 66.1; p < 0.001) as well as reduced scores for all functional scales (all p < 0.001). Additionally, CP patients reported a higher burden for all symptom items, with pain being the most prominent complaint (all p < 0.001). Constant pain (coefficient -11.3; p = 0.02), opioid based pain treatment (coefficient -19.7; p < 0.001) and alcoholic aetiology (coefficient -5.1; p = 0.03) were independently associated with lowered global health status. The final multivariable model explained 18% of the variance in global health status.

CONCLUSIONS

Patients with CP have significantly lower QOL compared to a population-based reference population. Factors independently associated with a lowered QOL are constant pain, opioid based pain treatment and alcohol aetiology. However, these factors only explain a fraction of QOL and additional factors need identification.

Preoperative Platelet to Lymphocyte Ratio as a Prognostic Factor for Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Various inflammatory markers have been investigated for a prognostic role in patients with resectable pancreatic cancer. However, the value of preoperative platelet to lymphocyte ratio (PLR) remains controversial. We performed a systematic review and meta-analysis of PLR as a preoperative prognostic factor for resectable pancreatic cancer.

MATERIAL AND METHODS

Systematic literature search was conducted for studies assessing PLR influence as a preoperative prognostic factor in resectable pancreatic cancer patients. Random-effects model was applied for pooling hazard ratios and 95% confidence intervals related to overall survival (OS) and disease-free survival (DFS).

RESULTS

Fourteen articles with 2,743 patients were included in the study. According to the analysis, high PLR had no correlation with decreased OS. Due to high heterogeneity among studies, subgroup analysis was performed. Better OS was associated with low PLR in Asian patients, patients with mixed type of operation performed, and patients with preoperative PLR ≤150. Low PLR was associated with significantly better DFS.

CONCLUSIONS

PLR is a predictive factor of better DFS in patients with resectable pancreatic cancer. However, available evidence does not support PLR as a reliable prognostic factor for OS.

Epigenetic Regulation of APAF-1 Through DNA Methylation in Pancreatic Cancer

BACKGROUND/AIM

Apoptotic peptidase activating factor 1 (APAF-1) is essential regulator of apoptosis and inactivation by DNA methylation is common event in numerous cancer types. We investigated the regulation of APAF-1 through DNA methylation in pancreatic cancer.

MATERIALS AND METHODS

Datasets from 44 patients after pancreatoduodenectomy and the pancreatic adenocarcinoma (PDAC) cell lines Capan-2 and MIA PaCa-2 treated with decitabine were analyzed by RT-PCR, immunoblotting, methylation-specific PCR analysis, apoptosis and viability assays to identify effects of APAF-1 regulation.

RESULTS

APAF-1 mRNA and protein levels were significantly down-regulated, and APAF-1 methylation status was associated with perineural invasion in PDAC. Decitabine inhibited cell viability and increased apoptosis rates, however failed to restore APAF-1 mRNA and protein levels in cells.

CONCLUSION

APAF-1 gene hypermethylation may contribute to the progression of PDAC through perineural invasion. Decitabine could sensitize pancreatic cancer cells to apoptosis and growth retardation, however, not directly through the APAF-1 demethylation process.

Multiple risk factors for diabetes mellitus in patients with chronic pancreatitis: A multicentre study of 1117 cases

BACKGROUND

Diabetes mellitus is a common complication of chronic pancreatitis. It is traditionally considered to develop as a consequence of beta cell loss, but there might be additional factors. Recent studies have highlighted the importance of type 2 diabetes-related risk factors in this context and population-based studies show increased risk of diabetes following acute pancreatitis. The aim of this study was to explore multiple risk factors for diabetes in patients with chronic pancreatitis.

METHODS

We conducted a multicentre, cross-sectional study of patients with definitive chronic pancreatitis according to the M-ANNHEIM criteria. We used multivariable logistic regression models to determine risk factors independently associated with diabetes.

RESULTS

The study included 1117 patients of whom 457 (40.9 %) had diabetes. The mean age was 52.8 ± 14.2 years and 67% were men. On multivariate analysis, parameters indicative of beta cell loss (pancreatic calcification, exocrine insufficiency, pancreatic resection) were confirmed as independent risk factors for diabetes (all p ≤ 0.02). In addition, type 2 diabetes-related risk factors (dyslipidaemia and overweight/obesity) were associated with the presence of diabetes (all p ≤ 0.002). Patients with a history of pancreatic fluid collections (indicative of previous attacks of acute pancreatitis) had a marginally increased risk of diabetes (p = 0.07).

CONCLUSION

In patients with chronic pancreatitis the presence of diabetes is associated with multiple risk factors including type 2 diabetes-related factors. Our observations attest to the understanding of this entity and may have implications for treatment.

Long-Term Impact of Iatrogenic Bile Duct Injury

BACKGROUND

Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis.

METHODS

We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients.

RESULTS

Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after "clinically successful" treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10-20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%.

CONCLUSIONS

The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.

Long-term Survival of Patient with Ampulla of Vater Metastasis of Renal Cell Carcinoma

Ampulla of Vater metastases from renal cell carcinoma are rare. The time between detection of the primary tumour and its metastasis may extend to years. Management should be aggressive, since the prognosis of renal cell carcinoma is unpredictable and curative surgery of metastases may extend patient survival and even lead to definite cure. Herein we report a case of long-term survival after successful surgical treatment of a renal cell carcinoma metastasis to the ampulla of Vater. A 62-year-old man with a history of renal cell carcinoma in the left kidney underwent a successful left nephrectomy. Eight months later duodenoscopy showed a tumour at the site of papilla of Vater. Biopsy confirmed the diagnosis of carcinoma. Contrast enhanced computer tomography scan verified the periampullary mass, dilatation of the pancreatic and the common bile duct. No radiological signs of either local advancement or distant metastases were present. Pylorus-preserving pancreatoduodenectomy with lymphadenectomy was performed. Pathology report disclosed metastatic lesions in the papilla of Vater from the clear cell carcinoma of the kidney. The postoperative course was uneventful, and the patient lived for 14 years after pancreatoduodenectomy and, following thorough investigations, was free from local and systemic recurrence. Pancreatoduodenectomy can provide long-term survival in selected cases with solitary papilla of Vater metastasis from renal cell carcinoma. Favourable long-term survival rates suggest that these patients should be considered candidates for pancreatoduodenectomy if experienced pancreatic surgeon is available and no other metastases are found.

Narrow line between benefit and harm: Additivity of hyperthermia to cisplatin cytotoxicity in different gastrointestinal cancer cells

AIM

To investigate the response to hyperthermia and chemotherapy, analyzing apoptosis, cytotoxicity, and cisplatin concentration in different digestive system cancer cells.

METHODS

AGS (gastric cancer cell line), Caco-2 (colon cancer cell line) and T3M4 (pancreatic cancer cell line) were treated by cisplatin and different temperature setting (37 °C to 45 °C) either in isolation, or in combination. Treatment lasted for one hour. 48 h after the treatment viability was evaluated by MTT, cell apoptosis by Annexin V-PE and 7ADD flow cytometry. Intracellular cisplatin concentration was measured immediately after the treatment, using mass spectrometry. Isobologram analysis was performed to evaluate the mathematical combined effect of temperature and cisplatin.

RESULTS

AGS cells were the most sensitive to isolated application of hyperthermia. Hyperthermia, in addition to cisplatin treatment, did not provoke a synergistic effect at intervals from 37 °C to 41 °C in neither cancer cell line. However, a temperature of 43 °C enhanced cisplatin cytotoxicity for Caco-2 cells. Moreover, isobologram analysis revealed mathematical antagonistic effects of cisplatin and temperature combined treatment in AGS cells; variations between synergistic, additive, and antagonistic effects in Caco-2 cells; and additive and antagonistic effects in T3M4 cells. Combined treatment enhanced initiation of cell apoptosis in AGS, Caco-2, and T3M4 cells by 61%, 20%, and 19% respectively. The increase of intracellular cisplatin concentration was observed at 43 °C by 30%, 20%, and 18% in AGS, Caco-2, and T3M4 cells, respectively.

CONCLUSION

In addition to cisplatin, hyperthermia up to 43 °C does not affect the viability of cancer cells in a synergistic manner.

How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification

AIM

To explore the outcomes and the appropriate treatment for patients with moderately severe acute pancreatitis (AP).

METHODS

Statistical analysis was performed on data from the prospectively collected database of 103 AP patients admitted to the Department of Surgery, Hospital of Lithuanian University of Health Sciences in 2008-2013. All patients were confirmed to have the diagnosis of AP during the first 24 h following admission. The severity of pancreatitis was assessed by MODS and APACHE II scale. Clinical course was re-evaluated after 24, 48 and 72 h. All patients were categorized into 3 groups based on Atlanta 2012 classification: Mild, moderately severe, and severe. Outcomes and management in moderately severe group were also compared to mild and severe cases according to Atlanta 1992 and 2012 classification.

RESULTS

Fifty-three-point four percent of patients had edematous while 46.6 % were diagnosed with necrotic AP. The most common cause of AP was alcohol (42.7%) followed by alimentary (26.2%), biliary (26.2%) and idiopathic (4.9%). Under Atlanta 1992 classification 56 (54.4%) cases were classified as “mild” and 47 (45.6%) as “severe”. Using the revised classification (Atlanta 2012), the patient stratification was different: 49 (47.6%) mild, 27 (26.2%) moderately severe and 27 (26.2%) severe AP cases. The two severe groups (Atlanta 1992 and Revised Atlanta 2012) did not show statistically significant differences in clinical parameters, including ICU stay, need for interventional treatment, infected pancreatic necrosis or mortality rates. The moderately severe group of 27 patients (according to Atlanta 2012) had significantly better outcomes when compared to those 47 patients classified as severe form of AP (according to Atlanta 1992) with lower incidence of necrosis and sepsis, lower APACHE II (P = 0.002) and MODS (P = 0.001) scores, shorter ICU stay, decreased need for interventional and surgical treatment.

CONCLUSION

Study shows that Atlanta 2012 criteria are more accurate, reduce unnecessary treatments for patients with mild and moderate severe pancreatitis, potentially resulting in health costs savings.

Response of OVCAR-3 Cells to Cisplatin and Hyperthermia: Does Hyperthermia Really Matter?

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) is proposed as a promising treatment method, but fundamental information about the contribution of hyperthermia to intraperitoneal chemotherapy is lacking. The purpose of this study was to investigate the cytotoxic effect of hyperthermia and cisplatin on OVCAR-3 cells in vitro.

MATERIALS AND METHODS

Imitating the typical clinical conditions of HIPEC, OVCAR-3 cells were exposed to hyperthermia and cisplatin for 1 h. MTT viability test, flow cytometric analysis, and real-time cell and isobologram analysis were performed.

RESULTS

Hyperthermia up to 42°C did not significantly increase the effect of cisplatin regarding the viability and apoptosis of OVCAR-3 cells. Moreover, an antagonistic effect of hyperthermia and cisplatin was revealed.

CONCLUSION

Our investigation of OVCAR-3 cells critically disputes the benefit of hyperthermia in ovarian cancer treatment. Further in vitro and in vivo research is essential for better understanding of the mechanisms of action of hyperthermia and its role in the treatment of epithelial ovarian cancer.

Preoperative Endoscopic Biliary Drainage May Negatively Impact Survival Following Pancreatoduodenectomy for Ampullary Cancer

BACKGROUND/AIMS

Ampullary carcinoma is a rare tumour with a high resectability rate. There is an increasing body of evidence indicating not only tumour-related factors, but also jaundice influence survival following curative resection. Several modalities for preoperative biliary drainage are available; however, routine preoperative endoscopic biliary drainage (PEBD) is not recommended. There is no sufficient data regarding the impact of PEBD on long-term outcomes. The aim of our study was to identify predictive factors of survival with special regard to PEBD in patients undergoing curative resection for ampullary carcinoma.

PATIENTS AND METHODS

Data from 64 consecutive patients with adenocarcinoma of the papilla of Vater who have been operated on was analysed. Overall survival was defined from the date of surgery to the date of death, or censored at the last patient contact. Survival analysis was determined by means of the Kaplan-Meier method. The significance of the demographic, clinical and histopathologic factors was ascertained by the log-rank test. A Cox proportional hazard model was used to determine independent prognostic factors of survival.

RESULTS

Twenty patients (31.2%) underwent PEBD. Univariate analysis revealed tumour-related factors, age over 70, and PEBD to negatively influence survival. Five of them (excluding T stage) were identified as the independent prognosticators, while PEBD appeared to be the most decisive factor. Median survival for patients who underwent PEBD was 25.3 months as compared to 112.9 months for those who did not. In conclusion, PEBD negatively affected long-term outcomes in our patients with resected ampullary carcinoma.

Impact of etiology on course and outcomes of severe acute pancreatitis

BACKGROUND AND OBJECTIVE

Since the influence of etiological factors on the course and outcomes of acute pancreatitis (AP) is not fully understood yet, the aim of the study was to compare the outcomes of alcoholic and biliary severe acute pancreatitis (SAP).

MATERIALS AND METHODS

We investigated 81 patients with alcoholic and biliary SAP. Demographic data, etiologic factors, severity scores, intra-abdominal pressure, imaging studies, interventions, and treatment outcomes were prospectively entered into specially maintained database and subsequently analyzed.

RESULTS

No statistically significant difference was observed in the prevalence of SAP in biliary and alcoholic AP groups (P=0.429). Although, in the biliary SAP group patients were predominantly elderly women (P=0.003), the total in-hospital stay was longer in alcoholic SAP patients (P=0.021). The abdominal compartment syndrome developed more frequently (P=0.041) and necrosectomy was more frequently performed in alcoholic SAP group (not statistically significant). Although not statistically significant, a lower mortality rate among biliary SAP patients (25.0% vs. 13.5%) was observed.

CONCLUSIONS

We defined a trend toward decreased incidence of infected necrosis in larger volume (≥30%) pancreatic necrosis, absence of abdominal compartment syndrome, lower rate of necrosectomies, shorter in-hospital stay, and an insignificantly reduced mortality rate in biliary SAP patients, indicating more favorable course of biliary SAP.

Factors influencing survival after pancreatoduodenectomy for ductal adenocarcinoma depend on patients' age

BACKGROUND

It is supposed that a prolonged lifetime will be associated with increased incidence of PDAC among the elderly. Some studies show a tendency toward decreased survival in the elderly patients following pancreatoduodenectomy for PDAC. The aim of this study was to evaluate factors, influencing survival following pancreatoduodenectomy for PDAC in different age groups.

METHODS

Data of 251 patients after pancreatoduodenectomy for PDAC between 1999 and 2012 were analyzed. The Kaplan-Meier method and log-rank test were used to calculate survival and to compare differences between groups. The Cox proportional hazard model was applied to indentify independent prognosticators.

RESULTS

The overall median survival was 14.9 months. Postoperative morbidity was 25.5% with a 5.1% mortality rate. No significant differences in the overall morbidity (22.4 vs. 29.6%) or mortality (2.8 vs. 8.3%) rates were observed between different patients' age groups (<70 years and >70 years). Multivariate analysis revealed R1 resection (HR 1.76) and poor tumor differentiation (G3-G4) (HR 1.48) were independent negative factors for survival in patients <70 years. Lymph-node metastases (N1) - HR 4.89 and perineural invasion - HR 2.73 were independent prognosticators in the elderly.

CONCLUSIONS

Our study highlighted different factors influencing long-term survival after pancreatoduodenectomy: R1 resection and poor tumor differentiation (G3-G4) were independent negative factors for survival in patients <70 years, while perineural invasion and lymph-node metastases result in worse survival among the elderly.

Congenital hyperinsulinism

Hyperinsulinism is the most common cause of hypoglycemia in infants. In many cases conservative treatment is not effective and surgical intervention is required. Differentiation between diffuse and focal forms and localization of focal lesions are the most important issues in preoperative management. We present a case of persistent infancy hyperinsulinism. Clinical presentation, conservative treatment modalities, diagnostic possibilities of focal and diffuse forms, and surgical treatment, which led to total recovery, are discussed.

Effects of prophylactic antibiotics in acute pancreatitis

OBJECTIVES

The use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients.

METHODS

The study population consisted of 210 patients treated for SAP. In Group 1 (n= 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n= 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate.

RESULTS

Ultrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P= 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P= 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P= 0.206] were performed more frequently and earlier [at 16.6 ± 7.8 days vs. 17.2 ± 6.7 days (P= 0.723); at 19.5 ± 9.4 days vs. 24.5 ± 14.2 days (P= 0.498), and at 22.6 ± 13.5 days vs. 26.7 ± 18.1 days (P= 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit.

CONCLUSIONS

The results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.

Whole blood DNA aberrant methylation in pancreatic adenocarcinoma shows association with the course of the disease: a pilot study

Pancreatic tumors are usually diagnosed at an advanced stage in the progression of the disease, thus reducing the survival chances of the patients. Non-invasive early detection would greatly enhance therapy and survival rates. Toward this aim, we investigated in a pilot study the power of methylation changes in whole blood as predictive markers for the detection of pancreatic tumors. We investigated methylation levels at selected CpG sites in the CpG rich regions at the promoter regions of p16, RARbeta, TNFRSF10C, APC, ACIN1, DAPK1, 3OST2, BCL2 and CD44 in the blood of 30 pancreatic tumor patients and in the blood of 49 matching controls. In addition, we studied LINE-1 and Alu repeats using degenerate amplification approach as a surrogate marker for genome-wide methylation. The site-specific methylation measurements at selected CpG sites were done by the SIRPH method. Our results show that in the patient's blood, tumor suppressor genes were slightly but significantly higher methylated at several CpG sites, while repeats were slightly less methylated compared to control blood. This was found to be significantly associated with higher risk for pancreatic ductal adenocarcinoma. Additionally, high methylation levels at TNFRSCF10C were associated with positive perineural spread of tumor cells, while higher methylation levels of TNFRSF10C and ACIN1 were significantly associated with shorter survival. This pilot study shows that methylation changes in blood could provide a promising method for early detection of pancreatic tumors. However, larger studies must be carried out to explore the clinical usefulness of a whole blood methylation based test for non-invasive early detection of pancreatic tumors.

Referral pattern, management, and long-term results of laparoscopic bile duct injuries: a case series of 44 patients

BACKGROUND AND OBJECTIVE

The incidence of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is higher than after open cholecystectomy, and the management of these lesions is still controversial. This study analyzed diagnostic and management strategies as well as long-term outcomes after BDI.

MATERIAL AND METHODS

A prospective database of patients with BDIs at the Clinic of Surgery was maintained during the 8-year period (2000-2007). The long-term results were evaluated during 2008-2010, after 36- to 120-month follow-up (median, 84 months).

RESULTS

In our series, 21 patients (48%) presented with minor and 23 (52%) with major BDIs. The overall incidence of BDIs was 0.24%. In 92% of cases in the minor BDI group, endoscopic stenting resulted in a good outcome. Major BDIs were treated by immediate, early, or delayed surgery depending on the timeliness of diagnosis and presence of biliary sepsis and/or cholangitis. The mean estimated time to failure after the initial treatment in the minor BDI group was significantly longer when compared with the major BDI group (114.3 vs. 81.8 months, log-rank test P=0.048). The hazard ratio of initial treatment failure after major versus minor BDIs was 6.06 (95% CI, 1.01-17.59). The mean estimated time to develop a biliary stricture after immediate, early, and delayed reconstructions was not different (P>0.05 in pairwise comparisons by log-rank test).

CONCLUSIONS

Minor BDIs are best served by endoscopy, while surgical repair may be an efficient option when injury is diagnosed intraoperatively. The timing of reconstruction after major BDIs does not portend a different outcome; consequently, every attempt to achieve infection control should be warranted. Referral to a tertiary care center should be encouraged to facilitate a proper classification of preoperative injuries and multidisciplinary approach.

Comparative diagnostic value of contrast-enhanced ultrasonography, computed tomography, and magnetic resonance imaging in diagnosis of hepatic hemangiomas

AIM

To compare the value of intravenous contrast-enhanced ultrasonography (US), intravenous contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis of hepatic hemangiomas.

MATERIAL AND METHODS

The study enrolled 48 patients, aged between 20 and 79 years (35 [72.9%] women, 13 [27.1%] men; mean age, 53.5+/-12.855 years), who were examined and treated in the Departments of Gastroenterology, Surgery, and Oncology, Hospital of Kaunas University of Medicine, in the year 2007. All patients underwent intravenous contrast-enhanced US, intravenous contrast-enhanced CT, and MRI and were diagnosed with hepatic hemangioma according to the findings of these examinations.

RESULTS

The size of hemangiomas was < or =2.0 cm in 20 cases (41.7%) and >2.0 cm in 28 (58.3%). No association between hepatic hemangioma and patient's age was found (chi(2)=0.547, df=2, P=0.761). Nearly one-third of hemangiomas were located in the segment IV of the left hepatic lobe. There were a few complicated hemangiomas in the study sample: 2 with calcification and 1 with necrosis. The sensitivity of CT in the diagnosis of hepatic hemangioma was 76.92%; specificity, 33.3%; positive prognostic value, 83.3%; and negative prognostic value, 25.0%. The sensitivity of intravenous contrast-enhanced US in the diagnosis of hepatic hemangioma was 77.8%; specificity, 100%; positive prognostic value, 100%; and negative prognostic value, 23.1%.

CONCLUSIONS

Intravenous contrast-enhanced US is more specific than intravenous contrast-enhanced CT in the diagnosis of hepatic hemangioma (P=0.0005) and has a higher positive prognostic value (P=0.001).

Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis

OBJECTIVE

Several tools have been developed for severity stratification in acute pancreatitis (AP). They include single biochemical markers and complex scoring systems, all of which aim at an early detection of severe AP to optimize monitoring and treatment of these patients. The aim of this study was to reassess and compare the value of some known and newly-introduced prognostic markers in the clinical context.

MATERIAL AND METHODS

We have conducted a prospective observational study. One hundred and eight patients with a diagnosis of AP and onset of the disease within last 72 h were included in this study. Clinical data and expression results of some serum biochemical markers were used for statistical analysis. The diagnostic performance of scores predicting severity and progression of AP, cut-off values, specificity, and sensitivity were established using receiver operating characteristic curve analysis.

RESULTS

Among single biochemical markers, C-reactive protein remains the most useful. Despite its delayed increase, it is accurate, cheap, and widely available. Interleukin-6 and macrophage migration inhibitory factor seem to be new promising parameters for use in clinical routine. Pancreas specific scores (Imrie-Glasgow, pancreatitis outcome prediction) and scores assessing organ dysfunction (acute physiology and chronic health evaluation II, multiple organ dysfunction score, and Marshall score) remain of value in determining the severity, complications, and possible outcome of AP.

CONCLUSIONS

Indication, timing, and consequences of the methods applied need to be carefully considered and incorporated into clinical assessments. Currently, there is no single prognostic marker that would cover the whole range of problems associated with the treatment of AP. The prediction of severity and progression of AP can be achieved using a series of accurate methods. The decision to undertake interventional or surgical treatment is the most complex task requiring both clinical judgment and meticulous monitoring of the patient.

Different profiles of cytokine expression during mild and severe acute pancreatitis

AIM

To study secretion patterns of pro- and anti-inflammatory cytokines, and activation of various cellular subsets of leukocytes in peripheral blood.

METHODS

We have conducted a prospective observational study. One hundred and eight patients with a diagnosis of acute pancreatitis and onset of the disease within last 72 h were included in this study. The mRNA expression of 25 different types of cytokines in white blood cells was determined by quantitative real time polymerase chain reaction. Levels of 8 different cytokines in blood serum were measured by enzyme linked immunosorbent assay. Clinical data and cytokine expression results were subjected to statistical analysis.

RESULTS

Severe and necrotizing acute pancreatitis (AP) is characterized by the significant depletion of circulating lymphocytes. Severe acute pancreatitis is associated with a typical systemic inflammatory response syndrome and over-expression of pro-inflammatory cytokines [interleukin (IL)-6, IL-8, macrophage migration inhibitory factor (MIF)]. Serum IL-6 and MIF concentrations are the best discriminators of severe and necrotizing AP as well as possible fatal outcome during the early course of the disease.

CONCLUSION

Deregulation of cellular immune system is a key event leading to severe and necrotizing AP. IL-6 and MIF could be used as early predictors of complications.

Radiofrequency ablation of liver tumors (II): clinical application and outcomes

Radiofrequency ablation is one of the alternatives in the management of liver tumors, especially in patients who are not candidates for surgery. The aim of this article is to review applicability of radiofrequency ablation achieving complete tumor destruction, utility of imaging techniques for patients' follow-up, indications for local ablative procedures, procedure-associated morbidity and mortality, and long-term results in patients with different tumors. The success of local thermal ablation consists in creating adequate volumes of tissue destruction with adequate "clear margin," depending on improved delivery of radiofrequency energy and modulated tissue biophysiology. Different volumes of coagulation necrosis are achieved applying different types of electrodes, pulsing energy sources, utilizing sophisticated ablation schemes. Some additional methods are used to increase the overall deposition of energy through alterations in tissue electrical conductivity, to improve heat retention within the tissue, and to modulate tolerance of tumor tissue to hyperthermia. Contrast-enhanced computed tomography, magnetic resonance imaging, ultrasound or positron emission tomography are applied to control the effectiveness of radiofrequency ablation. The long-term results of radiofrequency ablation are controversial.

Radiofrequency ablation of liver tumors (I): biological background

Majority of patients suffering from liver tumors are not candidates for surgery. Currently, minimal invasive techniques have become available for local destruction of hepatic tumors. Radiofrequency ablation is based on biological response to tissue hyperthermia. The aim of this article is to review available biological data on tissue destruction mechanisms. Experimental evidence shows that tissue injury following thermal ablation occurs in two distinct phases. The initial phase is direct injury, which is determined by energy applied, tumor biology, and tumor microenvironment. The temperature varies along the ablation zone and this is reflected by different morphological changes in affected tissues. The local hyperthermia alters metabolism, exacerbates tissue hypoxia, and increases thermosensitivity. The second phase - indirect injury - is observed after the cessation of heat stimulus. This phase represents a balance of several promoting and inhibiting mechanisms, such as induction of apoptosis, heat shock proteins, Kupffer cell activation, stimulation of the immune response, release of cytokines, and ischemia-reperfusion injury. A deeper understanding of the underlying mechanisms may possibly lead to refinements in radiofrequency ablation technology, resulting in advanced local tumor control and prolonged overall survival.

Interventional and surgical management of abdominal compartment syndrome in severe acute pancreatitis

BACKGROUND AND OBJECTIVE

Management of the abdominal compartment syndrome during severe acute pancreatitis by the open abdomen method is associated with considerable morbidity and resource utilization. Thus, the aim of this study was to evaluate the safety and efficacy of the ultrasound-guided percutaneous interventions and/or minimally invasive surgery in the treatment of abdominal compartment syndrome.

MATERIAL AND METHODS

Forty-four patients with severe acute pancreatitis were enrolled into a prospective study and treated according to the standard management protocol. Interventional and/or surgical management of abdominal compartment syndrome was employed in 6 (13.6%) cases. In the context of this study, we assessed the feasibility and effectiveness of subcutaneous fasciotomy of the anterior m. rectus abdominis sheath, as well as the role of ultrasound-guided drainage of intra-abdominal and peripancreatic fluid collections in the management of abdominal compartment syndrome.

RESULTS

Subcutaneous fasciotomy of the anterior m. rectus sheath and ultrasound-guided drainage of intra-abdominal and peripancreatic fluid collections seem to be safe (minor risk of bleeding or infection, closed abdomen, and easy care for the patient) and effective (resulted in a sustained decrease of intra-abdominal pressure to 13-16 mm Hg and regression of organ failures after intervention). Subcutaneous anterior m. rectus fasciotomy may appear to be beneficial in case of refractory abdominal compartment syndrome avoiding morbidity associated with the open abdomen technique.

CONCLUSIONS

Both the subcutaneous fasciotomy and ultrasound-guided drainage of intra-abdominal and/or peripancreatic fluid collections seem to be safe and effective alternatives in the management of abdominal compartment syndrome; however, prospective studies are needed to further evaluate their clinical role.

Apoptosis is activated in an early period after radiofrequency ablation of liver tissue

BACKGROUND/AIMS

Hyperthermia induced apoptosis may lead to tumor cell death thus expanding the volume of non-viable tissue and warrant a "safety margin" of at least 10mm to exclude the possibility of tumor recurrence. We carried out an experimental study to investigate the cellular injury produced by radiofrequency ablation in the area surrounding the ablated tissue and to describe early apoptotic processes in the transition zone following radiofrequency ablation procedure in a porcine liver model.

METHODOLOGY

Nine anesthetized pigs underwent laparotomy and local thermal ablation of the liver parenchyma. The ablated tissue and the surrounding parenchyma were investigated for apoptosis applying Western blot analysis and immunohistochemistry.

RESULTS

The active (cleaved) caspase-3 17-kDa subunit was detected in the transition zone one hour after ablative procedure at a distance of 9-10 mm from the rim of the necrosis zone. In contrast analysis of tissues in necrosis zone and in surrounding normal liver parenchyma revealed no markers of apoptotic activity.

CONCLUSION

We determined that apoptosis, leading to further cell death, is activated in the majority of cells in the transition zone, thus supporting the hypothesis that the "safety margin" of 10 mm is encompassed by the indirect thermal effect.

Early recognition of abdominal compartment syndrome in patients with acute pancreatitis

AIM: To assess the value of widely used clinical scores in the early identification of acute pancreatitis (AP) patients who are likely to suffer from intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).

METHODS: Patients (n = 44) with AP recruited in this study were divided into two groups (ACS and non-ACS) according to intra-abdominal pressure (IAP) determined by indirect measurement using the transvesical route via Foley bladder catheter. On admission and at regular intervals, the severity of the AP and presence of organ dysfunction were assessed utilizing different multifactorial prognostic systems: Glasgow-Imrie score, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, and Multiorgan Dysfunction Score (MODS). The diagnostic performance of scores predicting ACS development, cut-off values and specificity and sensitivity were established using receiver operating characteristic (ROC) curve analysis.

RESULTS: The incidence of ACS in our study population was 19.35%. IAP at admission in the ACS group was 22.0 (18.5-25.0) mmHg and 9.25 (3.0-12.4) mmHg in the non-ACS group (P < 0.01). Univariate statistical analysis revealed that patients in the ACS group had significantly higher multifactorial clinical scores (APACHE II, Glasgow-Imrie and MODS) on admission and higher maximal scores during hospitalization (P < 0.01). ROC curve analysis revealed that APACHE II, Glasgow-Imrie, and MODS are valuable tools for early prediction of ACS with high sensitivity and specificity, and that cut-off values are similar to those used for stratification of patients with severe acute pancreatitis (SAP).

CONCLUSION: IAH and ACS are rare findings in patients with mild AP. Based on the results of our study we recommend measuring the IAP in cases when patients present with SAP (APACHE II > 7; MODS > 2 or Glasgow-Imrie score > 3).

Percutaneous transhepatic biliary stenting: the first experience and results of the Hospital of Kaunas University of Medicine

Malignant biliary obstruction may be caused by cholangiocarcinoma and other nonbiliary carcinomas. At the time of diagnosis, 90% of patients with malignant obstructive jaundice may benefit from palliative treatment only. The objective of palliation is to relieve jaundice-related symptoms, prevent cholangitis, prolong survival, and improve quality of life. Percutaneous transhepatic biliary stenting is a well-established procedure used in patients with malignant obstruction of intra- and extrahepatic bile ducts. Twelve patients (9 women, 3 men; mean age, 68 years; range, 44-88 years) with inoperable malignant biliary obstruction were selected for percutaneous transhepatic biliary stenting with metallic stents in the period from January to December 2007. Technical and clinical success rate in this patient series was 83% and 80%, respectively. Minor and major complications occurred in 17% and 8% of cases, respectively, which is in the range reported by the others. This is our first experience of percutaneous transhepatic biliary stenting at the Hospital of Kaunas University of Medicine and, to our knowledge, the first reported patient series in Lithuania. These first results encourage expanding effective palliation by the employment of the percutaneous transhepatic biliary stenting in patients with nonresectable malignant biliary obstruction or in case of a recurrent disease after curative surgery. The cost effectiveness of percutaneous transhepatic biliary stenting against percutaneous transhepatic biliary drainage has yet to be evaluated in a prospective manner. However, immediate clinical benefits and positive short-term outcomes are unequivocal.

Venous thromboembolism and prophylaxis in cancer patients

Venous thromboembolism is a serious complication in patients with cancer. The seriousness of venous thromboembolism as a complication in cancer patients is becoming recognized as an important medical issue. Venous thromboembolism is a multifactorial disease associated with vascular endothelial damage, stasis of blood flow, and hypercoagulation. Preexisting morbidity, mutations of factor V Leiden or prothrombin 20210A, type of cancer, presence of metastases, use of central venous access, surgery, anesthesia, etc., increase the risk of venous thromboembolism. The patients with malignancies have a 7-fold increase in the risk of venous thromboembolism compared with individuals without cancer. Venous thromboembolism is the second most common cause of mortality in cancer patients. Venous thromboembolism is the most common cause of death at 30 days after surgery in patients undergoing surgery for cancer. Venous thromboembolism caused death in 46.3% of the cases after surgery for cancer. The Geneva prognostic index identified predictive factors for an adverse outcome, and the American College of Chest Physicians (ACCP) has suggested the guidelines for the prevention of venous tromboembolism in cancer patients. Cancer patients should receive appropriate venous thromboembolism prophylaxis. The methods used for venous thromboembolism prophylaxis are mechanical, pharmacological, or a combination of both. Well-timed thromboprophylaxis may protect patients from venous thromboembolism, early lethal outcome and even influence survival.

A comparison of the effectiveness of the early enteral and natural nutrition after pancreatoduodenectomy

The role of postoperative supplementary enteral nutrition after gastrointestinal surgery is controversial. Therefore, a randomized clinical trial with attempts to address the question of plenitude of routine application of postoperative enteral feeding on rate of postoperative complications following pancreatoduodenectomy was performed. Sixty patients undergoing pancreatoduodenectomy were blindly randomized into two groups: 30 patients in the first group received early enteral nutrition (EEN), while 30 patients in the second group were given early natural nutrition (ENN). The complications were evaluated according to definition criteria. All complications were further subdivided into infectious and noninfectious complications. Our data showed that patients in EEN group gained a larger amount of energy in kcal a day during the first five days after surgery in comparison to ENN group. There was a higher rate of postoperative complications in ENN group (53.3% vs 23.3%, P=0.03). This difference occurred mainly due to the higher incidence of infectious complications in ENN group (46.7% vs 16.7%, P=0.025). There were six cases of bacteriemia in this group of patients, while only one case was observed in EEN group (6 (20.0%) vs 1 (3.3%), P=0.1). The overall risk for the development of any type of infectious complication was 1.5 times higher in ENN group. In conclusion, this study suggests that supplementary postoperative enteral nutrition helps to decrease the rate of infectious complications in patients undergoing pancreatoduodenectomy, especially in those with a plasma albumin level of less than 34.5 g/L and/or ASA class III or higher, since natural nutrition is insufficient in this case.

Value of routine clinical tests in predicting the development of infected pancreatic necrosis in severe acute pancreatitis

OBJECTIVE

Fine-needle aspiration (FNA) is the procedure of choice for accurate diagnosis of infected necrosis. However, invasive procedures increase the risk of secondary pancreatic infection and the timing of FNA is still a matter for debate. Our objective was to assess the value of routine clinical tests to determine the minimal risk for infected necrosis, thereby optimizing timing and selection of patients for image-guided FNA.

MATERIAL AND METHODS

This prospective, non-randomized study comprised 90 patients with acute necrotizing pancreatitis. The data of 52 patients were used for discriminant function analysis to determine the differences between patients with infected necrosis and those with sterile necrosis. Cut-off points for variables were established using receiver operating characteristic (ROC) curve analysis and logistic regression was performed to determine the risk of infected necrosis. The clinical relevance of the defined diagnostic system was prospectively tested in a further 38 consecutive patients with acute necrotizing pancreatitis (ANP).

RESULTS

Discriminant function analysis showed that C-reactive protein (CRP) and white blood cell (WBC) values were significant discriminators between patients with sterile necrosis and those with infected necrosis. Cut-off values of 81 mg/l for CRP and 13 x 10(9)/l for WBC were established. The predicted risk for infected necrosis is approx. 1.4% if both tests are below the defined cut-off values. Consequently, we found FNA unnecessary in this subset of patients, unless otherwise indicated, as this invasive procedure per se carries a certain risk of bacterial contamination.

CONCLUSIONS

Routine clinical tests are helpful in diagnosing the development of infected necrosis. Based on the application of classification functions, the timing and selection of patients for image-guided FNA can be optimized.

Tigecycline is efficacious in the treatment of complicated intra-abdominal infections

BACKGROUND

Empiric treatment of complicated intra-abdominal infections (cIAI) represents a clinical challenge because of the diverse bacteriology and the emergence of bacterial resistance. The efficacy and safety of tigecycline (TGC), a first-in-class, expanded broad-spectrum glycylcycline antibiotic, were compared with imipenem/cilastatin (IMI/CIS) in patients with cIAI.

METHODS

In this prospective, double-blind, phase 3, multinational trial, patients were randomly assigned to intravenous (i.v.) TGC (100 mg initial dose, then 50 mg every 12 h) or i.v. IMI/CIS (500/500 mg every 6 h) for 5-14 days. Clinical response was assessed at the test-of-cure (TOC) visit (14-35 days after therapy) for microbiologically evaluable (ME) and microbiologically modified intent-to-treat (m-mITT) populations (co-primary efficacy endpoint populations in which cure/failure response rates were determined).

RESULTS

Of 817 mITT patients (i.e., received > or = 1 dose of study drug), 641 (78%) comprised the m-mITT cohort (322 TGC, 319 IMI/CIS) and 523 (64%) were ME (266 TGC, 256 IMI/CIS). Patients were predominantly white (88%) and male (59%) with a mean age of 49 years. The primary diagnoses for the mITT group were complicated appendicitis (41%), cholecystitis (22%), and intra-abdominal abscess (11%). For the ME population, clinical cure rates at TOC were 91.3% (242/265) for TGC versus 89.9% (232/258) for IMI/CIS (95% CI -4.0, 6.8; P<0.001). Corresponding clinical cure rates within the m-mITT population were 86.6% (279/322) for TGC versus 84.6% (270/319) for IMI/CIS (95% CI -3.7, 7.5; P<0.001 for noninferiority TGC versus IMI/CIS). The most commonly reported adverse events for TGC and IMI/CIS were nausea (17.6% TGC versus 13.3% IMI/CIS; P=0.100) and vomiting (12.6% TGC versus 9.2% IMI/CIS; P=0.144).

CONCLUSIONS

TGC is efficacious in the treatment of patients with cIAIs and TGC met per the protocol-specified statistical criteria for noninferiority to the comparator, IMI/CIS.

Meta-analysis of prophylactic parenteral antibiotic use in acute necrotizing pancreatitis

BACKGROUND

Acute pancreatitis is a potentially serious condition. It carries an overall mortality rate of 10-15%. Infectious complications account for approximately 80% of deaths from acute pancreatitis, and the question arises whether or not prophylactic antibiotics are useful in the prevention of these complications. Therefore, we performed an evidence-based analysis to assess the effect of available prophylactic antimicrobial treatment on the development of infected necrosis and sepsis, need for surgery, and mortality.

METHODS

A comprehensive PubMed search was performed evaluating the value of prophylactic administration of parenteral antibiotics in patients with acute necrotizing pancreatitis. Only articles published in English language between January 1990 and May 2006 were included. The search strategy initially generated 692 articles related to antibiotics in the treatment of acute pancreatitis. This number was reduced to 97 publications related to clinical trials on the same topic. Finally, 10 randomized clinical trials concerning prophylactic parenteral antibiotics in patients with acute necrotizing pancreatitis were identified. We have performed a meta-analysis using the random-effects model to assess the impact of prophylactic antibiotics on development of infected pancreatic necrosis and sepsis, need for surgery, and overall mortality.

RESULTS

Patients with necrotizing acute pancreatitis should receive effective antibiotic prophylaxis (i.e., carbapenems intravenously) to decrease the risk of infected necrosis and sepsis and need of surgery.

CONCLUSIONS

While providing new insights into key aspects of antibiotic prophylaxis, this evidence-based analysis highlights the need for further clinical trials regarding the indications for antibiotic prophylaxis.

Investigation of radiofrequency ablation process in liver tissue by finite element modeling and experiment

BACKGROUND

The character of ablation processes with high-frequency electrical current is similar in most biological tissues; however, quantitative characteristics are very different. Consequently, mathematical models of the process have a lot of specific aspects. In this study, we developed mathematical model of radiofrequency ablation in liver tissues with experimental validation of model in ex vivo porcine liver.

METHODS

The finite element nonlinear computational model for the simulation of the radiofrequency ablation processes and taking into account coupled electrical and thermal phenomena has been developed. The radiofrequency electric current processes are dominated by the active electric conductivity. The heat generation in biological tissues is determined by the electric current density. Simultaneously, the conductivity of the tissue is nonlinearly dependent upon the temperature of the tissue. The model has been implemented in COMSOL Multiphysics computational environment. Tests on physical characteristics of the thermal effect in ex vivo liver tissue have been performed and results compared.

RESULTS

Two oval-shaped zones of total and relative tissue destruction were highlighted. The principal distribution of the thermal effect is congruous with the theoretical model; however, the discrepancy of temperatures in experimental and theoretical models increases distally from active perfusion electrode.

CONCLUSIONS

Distribution of the thermal effect is congruous in the theoretical and experimental model; however, discrepancies of temperatures imply certain inadequacies of the mathematical models. Differences of computed and actual temperatures should be regarded predicting tissue ablation in clinical setting.

Results of surgical treatment of carcinoma of papilla of Vater

Adenocarcinoma is the most common malignant tumor of the ampulla, but in general, it is still rare. Therefore, these tumors are difficult to study, and most reports are of retrospective design. To evaluate immediate postoperative and long-term results, we have collected data prospectively in a specially created database on 21 consecutive patients with adenocarcinoma of the papilla of Vater, operated on at the Department of Surgery, Kaunas University of Medicine Hospital. All patients have undergone classical or pylorus-preserving pancreatoduodenectomy. Postoperative mortality was 4.8% and overall morbidity--28.6%. Pancreas-associated morbidity was 14.3% in the series. Actuarial 3-year survival among our patients was 89%. Stage I-II patients with T1-T2 and/or N negative tumors had significantly better 3-year survival when compared with stage III-IV patients, T3-T4 and/or N positive tumors. Patients with highly or moderately differentiated tumors (G1, G2) survived better than patients with poor cell differentiation (G3), though significant difference was not achieved. Results are satisfactory in terms of overall postoperative morbidity and mortality. Long-term survival pattern concerning T, N, and G status corresponds with other reports in literature, while the 3-year survival results are promising and speaks in favor of our surgical strategy.

Finite element modeling and experimental investigation of infiltration of sodium chloride solution into nonviable liver tissue

The aim of this study was to establish a mathematical model of the infiltration of sodium chloride solution into cadaveric liver tissue.

METHODS

The time law of the flow of the infiltrated fluid at every node of the finite element model was obtained in terms of Darcy's velocity, pressure, and volumetric saturation fraction. The model equations interpret the liver tissue as a porous medium taking into account the hydraulic conductivity, capacity, and absorption mechanisms. Capability of the cadaveric liver tissue to absorb the fluid is taken into account by means of the nonlinear relationship of hydraulic capacity and absorption coefficients against the volumetric saturation fraction. To explain certain inadequacies between the computational model and experiment, the idealized models of empty blood vessels in the vicinity of the injection probe have been used. The model has been implemented in computational environment COMSOL Multiphysics. Experimental procedures were performed to analyze fluid infiltration and to calculate volume of fluid, which might be injected into certain volume of nonviable liver tissue.

RESULTS

The necessary physical constants of hydraulic conductivity, capacity, and absorption of liver tissue have been determined by comparing the simulation results against the experimental data. The congruence of the modeling results against the experiment may be regarded as satisfactory.

CONCLUSION

The established model analyses distribution of injected solution taking into account the hydraulic conductivity, capacity, and absorption mechanisms of liver tissue. The obtained results are of importance developing complex models of electro-thermal heating coupled with heat advection by means of infiltrated sodium chloride solution.