Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy

INTRODUCTION

Afferent loop syndrome (ALS) is a recognised complication of foregut surgery caused by mechanical obstruction at the gastrojejunostomy anastomosis itself or at a point nearby. Acute ALS has only been reported following pancreaticoduodenectomy (PD) after several years due to recurrence of malignancy at the anastomotic site. We report five cases of acute ALS in the first postoperative week.

METHODS

The presentation, clinical findings and successful management of the 5 patients with ALS were obtained from a prospectively collected database of 300 PDs. All five patients with early acute ALS presented with signs and symptoms of a bile leak. Since the fifth patient, the surgical technique has been modified with the creation of a larger window in the transverse mesocolon and a Braun enteroenterostomy.

RESULTS

There have been no further incidents of ALS since the adoption of these modifications to the standard technique of PD and there has also been a reduction in postoperative bile leaks (6.4% vs 3.6%, p=0.416).

CONCLUSIONS

Acute ALS is a rare but important complication in the immediate postoperative period following PD and causes disruption to adjacent anastomoses, resulting in a bile leak. A prophylactic Braun anastomosis and wide mesocolic window may prevent this complication and subsequent deterioration.

Liver metastases from esophageal carcinoma: is there a role for surgical resection?

Esophageal cancer recurrence rates after esophagectomy are high, and locally recurrent or distant metastatic disease has poor prognosis. Management is limited to palliative chemotherapy and symptomatic interventions. We report our experience of four patients who have undergone successful liver resection for metastases from esophageal cancer. All underwent esophagectomy and were referred to our unit with metastatic recurrent liver disease, two with solitary metastases and two with multi-focal disease. The patients underwent multidisciplinary assessment and proceeded to a course of neoadjuvant chemotherapy followed by open or laparoscopic liver resection. Three patients were male, and the mean age was 57.5 (range 44-71) years. Response to chemotherapy ranged from partial to complete response. Following liver resection, two patients developed recurrent disease at 5 and 15 months, and both had disease-specific mortality at 10 and 21 months, respectively. The other two patients remain disease free at 22 and 92 months. Recurrent metastatic esophageal cancer continues to have a poor prognosis, and the majority of patients with liver involvement will not be candidates for hepatic resection. However, this series suggests that in selected patients, liver resection of metastases from esophageal cancer combined with neoadjuvant and adjuvant chemotherapy is feasible, but further research is required to determine whether this can offer a survival advantage.

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy

INTRODUCTION

Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN).

METHODS

Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male.

RESULTS

The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%).

CONCLUSIONS

Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.

Liver resection for colorectal cancer metastases involving the caudate lobe

BACKGROUND

Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer-involved resection margins of over 50 per cent being reported following caudate lobe resection.

METHODS

Outcomes of consecutive liver resections for colorectal metastases involving the caudate lobe between 1996 and 2009 were reviewed retrospectively, and compared with those after liver surgery without caudate resection.

RESULTS

Twenty-five patients underwent caudate and 432 non-caudate liver resection. Caudate resection was commonly performed as part of extended resection. There were no differences in operative complications (24 versus 21·1 per cent; P = 0·727) or blood loss (median 300 versus 250 ml; P = 0·234). The operating time was longer for caudate resection (median 283 versus 227 min; P = 0·024). Tumour size was larger in the caudate group (median 40 versus 27 mm; P = 0·018). Resection margins were smaller when the caudate lobe was involved by tumour, than in resections including tumour-free caudate or non-caudate resection; however, there was no difference in the proportion of completely excised tumours between caudate and non-caudate resections (96 versus 96·1 per cent; P = 0·990). One-year overall survival rates were 90 and 89·3 per cent respectively (P = 0·960), with 1-year recurrence-free survival rates of 62 and 71·2 per cent (P = 0·340).

CONCLUSION

Caudate lobe surgery for colorectal cancer liver metastases does not increase the incidence of resection margin involvement, although when the caudate lobe contains metastases the margins are significantly closer than in other resections.

'Close shave' in liver resection for colorectal liver metastases

INTRODUCTION

The optimal size of clear liver resection margin width in patients with colorectal liver metastases (CRLM) remains controversial. The aim of this study was to investigate the effects of margin width on long-term survival after liver resection for CRLM with a policy of standard neo-adjuvant chemotherapy.

METHODS

Consecutive patients (n=238) who underwent liver resection for CRLM were included over a ten-year period. All patients with synchronous or early (<2 years) metachronous tumours were treated with neo-adjuvant chemotherapy. Data were recorded prospectively.

RESULTS

Overall survival of the cohort at 1, 3 and 5 years were 90.3%, 68.1% and 56.1% respectively. The incidence of cancer involved resection margins (CIRM) was 5.8%. Patients with macroscopically involved resection margins had a poorer overall survival than those with microscopically involved margins (p=0.04). Involved resection margins had a poorer overall survival (p=0.002) than patients with clear margins. Width of clear resection margin did not affect long-term survival.

CONCLUSION

CIRM independently predicts poor outcome in patients with CRLM. Clear margin width does not affect survival. A standard policy of neo-adjuvant chemotherapy may be associated with a low incidence of CIRM and improved long-term outcome of sub-centimetre margin widths, resembling those with >1cm resection margins.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Reduced adhesion formation following laparoscopic versus open colorectal surgery

BACKGROUND

Adhesion formation is common after abdominal surgery. This study aimed to compare the extent of adhesion formation following laparoscopic and open colorectal surgery.

METHODS

An observational study was undertaken to identify adhesions in patients undergoing laparoscopy after previous laparoscopic or open colectomy. Adhesions were scored according to a system validated for interobserver (median kappa = 0.80) and intraobserver (kappa = 0.82) agreement. The primary endpoint was the overall adhesion score (0-10); a secondary endpoint was the adhesion score at the main incision site (0-6).

RESULTS

Forty-six patients were recruited (13 laparoscopic and 33 open colectomy). In most patients (n = 29), laparoscopy was performed for tumour staging before liver resection. The median (interquartile range) overall adhesion score was 7 (5-8) in the open group and 0 (0-3) in the laparoscopic group (P < 0.001). A similar difference was found for the main incision score: 6 (4-6) versus 0 (0-0) (P < 0.001).

CONCLUSION

There may be a reduction in adhesion formation following laparoscopic compared with open colectomy, although the small sample size limits this conclusion.

A 10-year study of outcome following hepatic resection for colorectal liver metastases - The effect of evaluation in a multidisciplinary team setting

AIMS

Colorectal carcinoma is the second most common cause of cancer death in the western world and nearly 50% of patients develop liver metastases. Many cancers are managed via a multidisciplinary team process. This study compares the long term outcome of patients with metastatic colorectal cancer referred via a multidisciplinary team including a liver surgeon (MDT) with those referred directly to a specialist hepatobiliary unit.

PATIENTS AND METHOD

This is a prospective study of 331 consecutive referrals made to a specialist hepatobiliary unit over ten years out of which 108 patients were referred via a colorectal MDT which included a liver surgeon and 223 were directly referred via colorectal MDTs without a liver surgeon. Pre-operative assessment and management were standardised and short and long term data were recorded.

RESULTS

Patients referred via the MDT had 1-, 3- and 5-year survival rates of 89.6%, 67.5% and 49.9% respectively and 1-, 3- and 5-year disease-free survival of 65.4%, 31% and 27.2% respectively. Patients referred directly had 1-, 3- and 5-year survival rates of 90.3%, 54.1% and 43.3% respectively and 1-, 3- and 5-year disease-free survival rates of 70.3%, 37.6% and 27.9% respectively. The difference in overall survival was significant (P=0.0001), although the difference in disease-free survival was not (P=0.21).

CONCLUSION

Assessing, managing and referring patients with metastatic colorectal cancer via a multidisciplinary team including a liver surgeon is associated with improved overall survival.

A comparison of right and extended right hepatectomy with all other hepatic resections for colorectal liver metastases: a ten-year study

AIMS

Colorectal liver metastases are treated by a combination of adjuvant chemotherapy followed by liver resection. In this study we compared all major right-sided resections with left or parenchymal sparing resections.

METHODS

Consecutive patients (n=283) who had successful hepatic resections for colorectal metastases from September 1996 to November 2006 were prospectively studied. Early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardised for all.

RESULTS

The 1-, 3- and 5-year overall survival rates in the RH group were 84.1%, 54.3% and 38.9%, respectively. The 1-, 3- and 5-year overall survival rates in the AOLR group were 95.4%, 65.9% and 53.3%, respectively. The difference was statistically significant (p=0.03). The 1-, 3- and 5-year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5%, respectively and 68.4%, 34.91% and 34.91%, respectively in the AOLR group (p=0.46). Operative mortality was 3.9% in the RH group and 0.7% in the AOLR group (p=0.04). Morbidity was 31.3% in the RH group and 18% in the AOLR group.

CONCLUSION

Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

The impact of staging laparoscopy prior to hepatic resection for colorectal metastases

AIMS

To evaluate the role of routine laparoscopy as a staging modality prior to laparotomy and hepatic resection for metastatic colorectal cancer.

METHODS

Prospectively collected data were analysed from a database. In the first half of the series patients underwent selective laparoscopy before proceeding to laparotomy and in the second part of the series laparoscopy was used routinely. Patients undergoing laparotomy directly were analysed in Group 1 and those having laparoscopy before laparotomy in Group 2. The ability of laparoscopy to pick up unresectable and extrahepatic disease, resectability rate and open and close laparotomy rate were recorded.

RESULTS

Of the 284 patients, 74 were in Group 1 (no laparoscopy) and 210 in Group 2 (laparoscopy as standard). The resectability rate was 81% in Group 1 and 87% in Group 2. The open and close laparotomy rate was 19% and 8%, respectively (p=0.025). In Group 2 alone, laparoscopy identified 39% of unresectable disease and prevented an open and close procedure.

CONCLUSIONS

Routine use of staging laparoscopy increases the resectability rate and reduces the inoperability rate in these patients.

Cholangiocarcinoma, renal cell carcinoma and parathyroid adenoma found synchronously in a patient on long-term methotrexate

Cases of patients developing lymphoma and cutaneous neoplasms after long-term methotrexate therapy are well documented in the literature; however, there are no reported cases of other neoplasms resulting from methotrexate therapy. A 52-year-old woman who had been on methotrexate for 9 years for psoriatic arthritis was found to have abnormal liver function tests on screening. Investigation with ultrasound, CT scanning and MRCP showed a hilar cholangiocarcinoma and a synchronous right renal tumour. A left hemi-hepatectomy extended to segments 5 and 8 with the formation of a hepaticojejunostomy was performed for a poorly differentiated infiltrative hilar cholangiocarcinoma. This was combined with a right radical nephrectomy for a T1 renal cell adenocarcinoma. Postoperative vomiting was subsequently found to be due to hypercalcaemia and primary hyperparathyroidism. A parathyroid adenoma was later excised. It seems likely that treatment with methotrexate was causal in the development of these three non-cutaneous neoplasms-two malignant and one benign.

Hepatic resection for breast cancer metastases

INTRODUCTION

Hepatic resection is an established modality of treatment for colorectal cancer metastases. Resection of breast cancer liver metastases remains controversial, but has been shown to be an effective treatment in selected cases. This study reports the outcome of 8 patients with liver metastases from breast cancer.

PATIENTS & METHODS

8 patients with liver metastases from previously treated breast cancer were referred for hepatic resection between September 1996 and December 2002. Six were eligible for liver resection. The mean age was 45.8 years. The resections performed included 1 segmentectomy and 5 hemihepatectomies of which one was an extended hemihepatectomy. One patient had a repeat hepatectomy 44 months after the first resection.

RESULTS

There were no postoperative deaths or major morbidity. The resectability rate was 75%. Follow-up periods range from 6 to 70 months with a median survival of 31 months following resection. There have been 2 deaths, one died of recurrence in the residual liver at 6 months and one died disease-free from a stroke. Of the remaining 4 patients, 1 has had a further liver resection at 44 months following which she is alive and 'disease-free' at 70 months. The one patient with peritoneal recurrence is alive 49 months after her liver resection with 2 patients remaining disease-free.

CONCLUSION

Hepatic resection for breast cancer liver metastases is a safe procedure with low morbidity and mortality.

The measurement of liver resection margins

BACKGROUND

All tissue shrinks to some degree when placed in formalin fixative solution. The degree of shrinkage of liver tissue has particular relevance to the measurement of resection margins, as the current recommendation is that the surgeon should aim to achieve a resection margin of at least 1 cm. We were unable to find any published data concerning shrinkage of liver tissue in formalin. The aim of this study was therefore to quantify the shrinkage of liver specimens in the fixation process.

METHODS

Distances of 10, 30 and 50 mm were measured and marked on 18 fresh liver specimens. The specimens were then fixed in 10% formalin solution for 24 h, and the distances were re-measured to assess shrinkage.

RESULTS

The observed shrinkage at all three distances was <10% after 24 h in formalin. The degree of shrinkage was statistically significant.

CONCLUSION

Although the degree of shrinkage is small, it may be important when considering resection margins of the order of 1 cm and should therefore be taken into account.

Long-term survival with stage IV poorly differentiated pancreatic adenocarcinoma

BACKGROUND

Metastatic poorly differentiated adenocarcinoma of the pancreas has a poor outcome despite the use of various chemotherapy regimes.

CASE OUTLINE

A 57-year-old woman presented with a 3-month history of generalised abdominal pain associated with weight loss. Computed tomography (CT) showed a large tumour in the head and body of pancreas, and needle biopsy confirmed a poorly differentiated adenocarcinoma. Laparoscopy revealed liver metastases in both lobes, again histologically shown to be poorly differentiated adenocarcinoma. Six cycles of cisplatin, epirubicin and infusional 5-fluorouracil were given. Five years later the patient remains completely well. Repeat CT scans show a complete radiological response.

DISCUSSION

Previous studies using numerous chemotherapy regimes have not significantly altered the outcome of pancreatic cancer. To the best of our knowledge this is the longest surviving case of a patient with advanced metastatic adenocarcinoma (stage IV) of the pancreas treated with chemotherapy.

A review of techniques for liver resection

BACKGROUND

There has been a significant increase in the number of hepatic resections performed. The aim of this review was to assess available techniques for liver resection and their application.

METHODS

A literature review was performed based on a Medline search to identify articles on liver resection. Keywords included liver resection, liver neoplasm, cancer, colorectal metastases and hepatocellular carcinoma.

RESULTS

Improved understanding of the segmental anatomy of the liver has resulted in the evolution of liver resection. The development of new approaches to the biliovascular tree, combined with clamping to produce ischaemic demarcation, has been important in demonstrating segmental boundaries for resection. The combination of methods of vascular control such as the Pringle manoeuvre and techniques of parenchymal resection such as ultrasonic dissection allows hepatic resection with minimal blood loss and morbidity.

CONCLUSIONS

Application of refined techniques for liver resection by specialised units allows liver resection to be performed on both normal and cirrhotic livers with low morbidity and mortality.

Giant sigmoid diverticulum causing colonic and urinary obstruction

Diverticulosis of the colon is a fairly common disease, but a solitary giant diverticulum is relatively rare. This case presented with symptoms of urinary and bowel obstruction.

Regional pancreatectomy and transverse colectomy with mesenteric vascular reconstruction for inflammatory pseudotumour of the head of pancreas and mesenteric root

BACKGROUND

Inflammatory myofibroblastic pseudotumour is a rare pancreatic lesion.

CASE OUTLINE

A 32-year-old woman with such a tumour was treated by a radical operation comprising proximal pancreatic-duodenectomy (Whipple Procedure) and transverse colectomy with resection and reconstruction of the superior mesenteric artery and vein. She remains well 6 years later.

DISCUSSION

The importance of aggressive surgical clearance rather than chemotherapy is highlighted in the management of patients with these unusual tumours.

Anatomical variations of the extrahepatic biliary tree: review of the world literature

The anatomy facing a surgeon during cholecystectomy involves complex relationships between the hepatic artery, extrahepatic biliary tree, and gallbladder. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. Equally important, however, is an understanding of congenital variation of biliary and vascular anatomy, as the literature abounds with reports of specific anatomical variations, and their operative implications. This article reviews the world literature on congenital variation of extrahepatic biliary anatomy.

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Pancreatic vascular regulation in chronic pancreatitis in cats

In experimental obstructive chronic pancreatitis the normal hyperaemic response to secretory stimulation is lost, suggesting abnormal vascular regulation. Vascular regulatory mechanisms were investigated by observing the effect of increments in portal pressure on pancreatic blood flow in normal cats and cats with chronic pancreatitis. Normal cats maintained pancreatic blood flow until portal pressure was > 15 mm Hg, after which it decreased. Total vascular resistance decreased until the portal pressure was 15 mm Hg and increased thereafter. These observations suggested that metabolic regulatory mechanisms prevailed while portal pressure was in the physiological range but myogenic mechanisms became dominant during portal hypertension. In chronic pancreatitis the basal pancreatic blood flow was reduced and was inversely proportional to portal pressure. Total vascular resistance increased as portal pressure increased. In chronic pancreatitis myogenic regulatory responses prevailed at all levels of portal pressure. In conclusion, intrinsic regulation of pancreatic blood flow was abnormal in cats with chronic pancreatitis. The loss of the predominance of metabolic regulation over the normal range of portal pressure may partly explain the reduction of pancreatic blood flow in response to secretory stimulation.

Routes of spread of pathogens into the pancreas in a feline model of acute pancreatitis

The routes of spread of pathogens into the pancreas in acute pancreatitis were investigated. Four experiments were performed: (1) cats with and without acute pancreatitis were given 10(7) Escherichia coli (E coli) intravenously, (2) in cats with acute pancreatitis 10(8) E coli was placed in the colon. In half of them the colon was then enclosed in an impermeable bag to prevent transmural spread. (3) E coli (10(4)) was placed in the pancreatic duct in cats with and without acute pancreatitis. (4) In cats with acute pancreatitis 10(5) E coli was placed in the gall bladder. In half of them the common bile duct was ligated to prevent biliary-pancreatic reflux. After 24 hours, intravenous E coli infected the pancreas in six of nine cats with acute pancreatitis and three of 10 controls. After 72 hours E coli spread to the pancreas from the colon in six of nine cats with acute pancreatitis. This was prevented by enclosing the colon in an impermeable bag (p = 0.02). In five of six cats with acute pancreatitis and five of six controls E coli placed in the pancreatic duct colonised the pancreas within 24 hours. Pancreatic colonisation from the gall bladder occurred in five of six cats with a patent common bile duct and in three of six with an obstructed common bile duct. In conclusion, in cats E coli can spread to the pancreas by the blood stream, transmurally from the colon, and by reflux into the pancreatic duct.

Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum

Over 14 years 276 patients with rectal cancer underwent surgery; 219 who underwent low anterior resection of the rectum with total mesorectal excision were studied. There were 24 (11.0 per cent) major anastomotic leaks associated with peritonitis or a pelvic collection and 14 (6.4 per cent) minor leaks that were asymptomatic and detected by contrast enema. All major leaks occurred at an anastomotic height of less than 6 cm (P = 0.08). The abdominoperineal excision rate was 9.1 per cent. Major leaks were associated with failure to defunction in 11 of 62 patients and with a defunctioning colostomy in 13 of 157 (P = 0.03). Of the 24 patients with major leaks seven developed peritonitis, one with a defunctioned anastomosis (P = 0.002), and three died (P = 0.02). Use of the sigmoid colon led to major leakage in seven of 32 patients compared with 17 of 187 when the splenic flexure was employed (P = 0.05). There was no increase in the local recurrence rate but only nine patients with major leakage and a temporary stoma have had these closed. Key technical factors include: a clean dry pelvic cavity, pulsatile colonic blood supply, suction drainage started during closure and mobilization of ample tissue to fill the pelvic space.

Histochemical and metabolic changes in functioning ileal pouches after proctocolectomy for familial adenomatous polyposis and ulcerative colitis

Ulcerative colitis and familial adenomatous polyposis may be treated by proctocolectomy with ileal pouch reconstruction, anastomosing the pouch to the anus. We studied 24 patients who underwent this procedure, of whom 12 had ulcerative colitis and 12 had familial adenomatous polyposis. Ileal absorption was investigated and pouch histology assessed more than one year after closure of the protective defunctioning loop ileostomy. The results showed a reduction in bile acid reabsorption and vitamin B12 absorption. These observations were associated with a morphologic transformation in the small bowel mucosa to large bowel mucosa. In 10 of the 12 colitis patients one or more of the histological features of the original disease (such as active inflammation, increased regeneration, atypia) were evident. Histological examination of the biopsies taken from the polyposis patients showed areas with an excess of sialomucins.

Sources of pancreatic pathogens in acute pancreatitis in cats

The source(s) of pancreatic pathogens is uncertain, although the colon is usually implicated. We studied whether pathogens may spread from different sites in a feline model of the disease. Acute pancreatitis was induced using a standard technique and a distinctive clinical strain of Escherichia coli as the marker bacterium. E. coli were placed in the colon, gall bladder, main pancreatic duct, or obstructed renal pelvis of control cats (no pancreatitis) and acute pancreatitis cats. Pancreases were colonized from each source, whether or not pancreatitis was present. The pancreatic colonization rate was greater in acute pancreatitis only when E. coli had been placed in the colon. In conclusion, E. coli may spread to the pancreas from different sources. The high rate of pancreatic colonization in both control and inflamed glands suggested that, clinically, bacteria may spread to the pancreas more frequently than is currently thought.

Antimicrobial treatment of pancreatic infection in cats

An investigation examined the efficacy of antibiotics in a novel feline model of pancreatic infection in acute pancreatitis. Acute pancreatitis was induced in cats using an established technique. In control animals (no pancreatitis) and cats with pancreatitis, Escherichia coli (10(4) in 0.1 ml) was placed in the pancreatic duct. Reoperation was performed after 24 h in six controls and six cats with pancreatitis. E. coli was cultured from the pancreas in five control animals and five cats with pancreatitis. Reoperation was performed after 1 week in ten controls, in 11 cats with pancreatitis and in nine with pancreatitis that were treated with cefotaxime (50 mg/kg intramuscularly three times daily) started 12 h after the induction of pancreatitis and administration of E. coli. Pancreatic infection developed in eight cats with pancreatitis compared with none of the cefotaxime-treated animals and none of the controls (P < 0.05). Cefotaxime reached bactericidal levels in pancreatic tissue and juice. In conclusion, ductal administration of E. coli caused pancreatic infection only in cats with acute pancreatitis. Early administration of an appropriate antibiotic was effective in treating pancreatic infection in acute pancreatitis.

Dopamine in models of alcoholic acute pancreatitis

Acute oedematous pancreatitis and acute haemorrhagic pancreatitis were studied using the low pressure duct perfusion models of alcoholic pancreatitis in cats. After creating either form over 24 hours, each pancreas was histologically graded and assigned an inflammatory score (0-16; absent-severe). Urinary trypsinogen activation peptide concentrations were also used as a measure of severity. Using the model of acute haemorrhagic pancreatitis, it was previously shown that low dose dopamine (5 micrograms/kg.m) reduced the inflammatory score at 24 hours and that this effect was mediated by a reduction in pancreatic microvascular permeability acting via dopaminergic and beta adrenergic receptors. Further studies were conducted and are reported here. In experiment 1 different doses of dopamine in established alcoholic acute haemorrhagic pancreatitis were studied. In group 1 control cats (no dopamine), the inflammatory score was 10.5 (interquartile range (IQR)4). In groups 2, 3, and 4, haemorrhagic pancreatitis was induced. Twelve hours later dopamine was infused for six hours, in the doses of 2 micrograms/kg.min, 5 micrograms/kg.min, and 50 micrograms/kg.min respectively. The inflammatory score in group 2 was 7 (IQR 0.5, p < 0.05 v group 1), in group 3 it was 7 (IQR 2, p < 0.05 v group 1), and in group 4 it was 7 (IQR 4, p < 0.05 v group 1). This was matched by significantly lower levels of urinary tripsinogen activation peptide at 24 hours. In experiment 2 (group 5) we tried to reduce microvascular permeability further by combining dopamine with antihistamines, but there was no improvement in the inflammatory score. As oedematous pancreatitis is the commoner and milder form of acute pancreatitis in clinical practice, in experiment 3 we looked at the effect of dopamine in this model. In group 6 control cats (no treatment), the inflammatory score was 7 (IQR 3, p < 0.05 v group 1). In group 7 cats given dopamine (5 micrograms/kg.min for six hours) from 12 hours after the onset of actue oedematous pancreatitis, the inflammatory score was reduced to 4(IQR 2, p < 0.05 v group 6). This was matched by a significant reduction in the 24 hour urinary tripsin activation peptide concentration.

Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct

Chronic pancreatitis is characterized by persistent and severe pain, which can be relieved by decompression of the main pancreatic duct (MPD). Both ductal and interstitial pressures have been shown to be increased in chronic pancreatitis in patients. A study was carried out of pancreatic interstitial pressure and pancreatic blood flow in normal cats and those in which chronic obstructive pancreatitis had been induced 5 weeks earlier to determine the effect of decompression of the MPD. In the normal pancreas, median(interquartile range (i.q.r.)) basal interstitial pressure was 0.05(1.2) mmHg and median(i.q.r.) basal pancreatic blood flow 58.3(24.3) ml per min per 100 g. Secretory stimulation did not change the interstitial pressure significantly, but was associated with a 40 per cent increase in median(i.q.r.) blood flow to 81.8(45.8) ml per min per 100 g. In contrast, in chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.5) mmHg, which was significantly higher than in the normal gland, and median(i.q.r.) pancreatic blood flow was 38.3(9.8) ml per min per 100 g, significantly lower than in the normal pancreas. Furthermore, secretory stimulation was associated with a significant increase in median(i.q.r.) interstitial pressure to 3.3(1.6) mmHg and a simultaneous decrease in median(i.q.r.) blood flow to 31.5(13.7) ml per min per 100 g. After decompression of the MPD in cats with chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.4) mmHg and on secretory stimulation 1.8(1.5) mmHg. Decompression thus prevented the increase in interstitial pressure seen in the animals with obstruction. In contrast, ductal decompression improved the median(i.q.r.) basal pancreatic blood flow to 45.9(38.4) ml per min per 100 g and, furthermore, this increased significantly on secretory stimulation to a median(i.q.r.) of 81.4(47.8) ml per min per 100 g. Decompression thus restored the normal pattern of secretory hyperaemia. Within the confines of this model, these observations demonstrate that chronic obstructive pancreatitis exhibits a compartment syndrome that is relieved by duct drainage.

The differences in early haemodynamic response between surgery and angioplasty after successful re-opening of the superficial femoral artery

In 40 patients with superficial femoral artery disease we prospectively evaluated the effect of angioplasty (n = 20) or femoropopliteal bypass (n = 20) on the ankle-brachial pressure index (ABI) using the Doppler ultrasound probe. The ABI was measured as a baseline 1 day before the procedure, 1 day after the procedure and 30 days later. In the angioplasty group the baseline ABI was 0.57 (0.11), increasing to 0.74 (0.26) 1 day postangioplasty and increasing further to 0.88 (0.26) after 30 days. The increase in ABI over 30 days was significantly greater than the increase over 1 day. In the femoropopliteal bypass group the baseline ABI was lower at 0.46 (0.17). However 1 day postoperatively it had increased to 0.92 (0.2) with almost no further increase at 30 days [0.95 (0.17)]. We concluded that by contrast to a surgical bypass where there was a large improvement in the ABI over the first day, the ABI following angioplasty continued to improve significantly beyond the first day.

The Diagnosis and Management of Arteritis

Inflammatory arterial disease is often insidious and associated with a substantial morbidity and mortality. Early recognition is vital. Patients with arteritis ( n=106) were studied and divided into five groups. Two of these were subgroups of giant cell arteritis classified by site into either cranial —arteritis (66), or upper limb arteritis (7). Three other groups were identified; chronic periaortitis (with or without inflammatory aortic aneurysm) (7), polyarteritis nodosa (14), and small vessel arteritis (12). Clinicians are not sufficiently aware of arteritis and its many atypical presentations. Delay in management is associated with a significant morbidity and mortality. In this district serving 200 000 people at least one patient per month is seriously at risk from the disease. Improved outlook depends on early recognition of the clinical syndromes and rapid appropriate treatment.

The diagnosis and management of arteritis

Inflammatory arterial disease is often insidious and associated with a substantial morbidity and mortality. Early recognition is vital. Patients with arteritis (n = 106) were studied and divided into five groups. Two of these were subgroups of giant cell arteritis classified by site into either cranial arteritis (66), or upper limb arteritis (7). Three other groups were identified; chronic periaortitis (with or without inflammatory aortic aneurysm) (7), polyarteritis nodosa (14), and small vessel arteritis (12). Clinicians are not sufficiently aware of arteritis and its many atypical presentations. Delay in management is associated with a significant morbidity and mortality. In this district serving 200,000 people at least one patient per month is seriously at risk from the disease. Improved outlook depends on early recognition of the clinical syndromes and rapid appropriate treatment.

The use of Coca-Cola in the management of bolus obstruction in benign oesophageal stricture

Oesophageal stricture is a complication of oesophageal reflux and may itself be complicated by bolus obstruction. We reviewed the records of patients presenting with dysphagia and who were found to have benign oesophageal strictures. We studied the outcome of bolus obstruction in 13 episodes affecting eight patients. In six episodes Coca-Cola was administered on the day before endoscopy, and in all these patients the bolus had cleared. In seven episodes nothing was administered before endoscopy, and in all seven a bolus was evident at endoscopy. In five of these seven the bolus was removed piecemeal and in each of these instances the endoscope had to be passed between two and five times. In the remaining two instances the procedure was abandoned and the patients returned to the ward for the administration of Coca-Cola. At subsequent endoscopy these patients were found to be clear of any bolus. These results suggest that the administration of Coca-Cola (or other aerated drinks) may clear a bolus in the acutely obstructed oesophagus.