Audrius Šileikis

Value of adipokines in predicting the severity of acute pancreatitis: Comprehensive review

AIM To analyze the prognostic value of adipokines in predicting the course, complications and fatal outcome of acute pancreatitis (AP). METHODS We performed the search of PubMed database and the systemic analysis of the literature for both experimental and human studies on prognostic value of adipokines in AP for period 2002-2012. Only the papers that described the use of adipokines for prediction of severity and/or complications of AP were selected for further analysis. Each article had to contain information about the levels of measured adipokines, diagnosis and verification of AP, to specify presence of pancreatic necrosis, organ dysfunction and/or mortality rates. From the very beginning, study was carried out adhering to the PRISMA checklist and flowchart for systemic reviews. To assess quality of all included human studies, the Quality Assessment of Diagnostic Accuracy Studies tool was used. Because of the high heterogeneity between the studies, it was decided to refrain from the statistical processing or meta-analysis of the available data. RESULTS Nine human and three experimental studies were included into review. In experimental studies significant differences between leptin concentrations at 24 and 48 h in control, acute edematous and acute necrotizing pancreatitis groups were found (P = 0.027 and P < 0.001). In human studies significant differences between leptin and resitin concentrations in control and acute pancreatitis groups were found. 1-3 d serum adiponectin threshold of 4.5 μg/mL correctly classified the severity of 81% of patients with AP. This threshold yielded a sensitivity of 70%, specificity 85%, positive predictive value 64%, negative predictive value88% (area under curve 0.75). Resistin and visfatin concentrations differ significantly between mild and severe acute pancreatitis groups, they correlate with severity of disease, need for interventions and outcome. Both adipokines are good markers for parapancreatic necrosis and the cut-off values of 11.9 ng/mL and 1.8 ng/mL respectively predict the high ranges of radiological scores. However, the review revealed that all nine human studies with adipokines are very different in terms of methodology and objectives, so it is difficult to generalize their results. It seems that concentrations of the leptin and resistin increases significantly in patients with acute pancreatitis compared with controls. Serum levels of adiponectin, visfatin and especially resitin (positive correlation with Acute Physiology and Chronic Health Evaluation II, Ranson and C-reactive protein) are significantly different in mild acute pancreatitis and severe acute pancreatitis patients, so, they can serve as a markers for the disease severity prediction. Resistin and visfatin can also be used for pancreatic and parapancreatic necrosis prediction, interventions needs and possible, outcome. CONCLUSION High levels of adipokines could allow for prediction of a severe disease course and outcome even in small pancreatic lesions on computed tomography scans.

Hypertriglyceridemia-Induced Acute Pancreatitis in Pregnancy

CONTEXT Hypertriglyceridemia is a well known phenomenon of pregnancy occurring due to physiologic changes in sex hormone levels. Occasionally, it could lead to development of acute pancreatitis. Gestational hypertriglyceridemia-induced acute pancreatitis occurs in pregnant women usually with preexisting abnormalities of the lipid metabolism and is associated with additional diagnostic and therapeutic challenges related to hypertriglyceridemia and pregnancy. CASE REPORT We present a case of the hypertriglyceridemia-induced acute pancreatitis in pregnant woman with no previous history of lipid abnormality and pregnancy as the only known triggering factor for hypertriglyceridemia. CONCLUSIONS Hypertriglyceridemia-induced acute pancreatitis is a rare complication of pregnancy; however, it should be suspected in all pregnant patients admitted for nonobsteric abdominal pain.

Minimally invasive management of pancreatic pseudocysts

Introduction The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PP) are the current minimally invasive management options. Indications, and early and late results of endoscopic and laparoscopic approaches are being discussed. Aim To present experience in treatment of PP by laparoscopic pseudocystogastrostomy (LPGS) and endoscopic pseudocystogastrostomy (EPGS) and to compare results, feasibility and safety. Material and methods Thirty patients underwent surgical intervention: 18 patients – LPGS (group I), 12 – EPGS (group II). Groups were compared by age, gender, pancreatic pseudocysts’s age, diameter and localization, as well as intraoperative, early and late postoperative complications. Results Gender distribution, group I: 14 (77.8%) men and 4 (22.2%) women, group II: 4 (33.3%) men and 8 (66.7%) women, p = 0.02. Average cyst diameter: group I – 149.9 ±52.1 mm, group II – 119 ±37.9 mm, p = 0.07. Average time between diagnosis and operation performance: group I – 12 (3-60) months, group II – 8 (2-36) months, p = 0.19. Neither in group I nor in group II did intraoperative complications occur. Early postoperative complications were divided into minor and major. Early minor complications: group I – 2 (11.1%), group II – 0, p = 0.5. Early major complications: group I – 0, group II – 2 (16.7%), p = 0.15. Late postoperative complications: group I – 0, group II – 1 (8.3%), p = 0.4. In group I there was no case, whereas in II group there was 1 (8.3%) case of recidivation, p = 0.4. Conclusions For selected patients both minimally invasive methods are equally safe an effective. For comprehensive evaluation of methods prospective trials are needed.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis

Introduction One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion. Aim We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method. Material and methods We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy. Results There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days. Conclusions Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Metabolomics in pancreatic cancer biomarkers research.

Pancreatic cancer is one of the worst prognoses of all malignancies. More than 40,000 deaths a year from this disease are observed in European Union alone. The only possibly curative treatment of pancreatic cancer is surgery, yet only 15–20% of patients have operable disease and even patients, which go through surgery and adjuvant chemotherapy, survival is less than 30%. The sensitive and specific biomarkers which could be used for the advance of early diagnostics are needed and constantly researched. Metabolomics is a technology which analyzes the concentrations of low-molecular-weight metabolites (the metabolome) has lately effectively developed due to the improvements in analytical technology. Metabolome analysis can be a one of the useful approaches for the biomarker discovery and disease diagnosis. Here we discuss recent discoveries in the field of pancreatic cancer metabolomics as well as the most promising biomarkers for diagnostics, prognosis and prediction.

Video-assisted loboisthmectomy by the subclavicular approach. A case report

The main advantage of minimally invasive thyroidectomy is a good cosmetic effect. Minimally invasive video-assisted thyroidectomy (MIVAT) is performed without gas insufflation in contrast to endoscopic thyroidectomy. In general, MIVAT is carried out through an incision in the middle part of the neck, not covered with clothes. The MIVAT thyroid lobectomy can also be done through the subclavicular approach. We describe a case of a 19-year-old female patient with a tumour of the left side of the neck. Thyroid ultrasound scan (UST) with thyroid fine-needle aspiration and cytological examination (FNAC) were performed. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and anti-tyreoperoxidase (ATPO) were checked. Video-assisted hemithyroidectomy was performed through an incision below the left clavicle. Intraoperative pathology examination of the specimen was carried out. The UST showed a solitary 13 mm × 23 mm nodule in the left lobe of the thyroid, the FNAC showed benign pathology. Thyroid function tests were normal (TSH 0.90 mIU/l; FT3 4.70 pmol/l). Video-assisted hemithyroidectomy was done through the incision below the left clavicle. Histopathological examination proved thyroid hyperplasia nodosum. There were no intra- or postoperative complications. The patient was discharged on the second day. Clinical and cosmetic outcomes 2 months after surgery were good. Minimally invasive video-assisted thyroid lobectomy performed via the subclavicular area is feasible and provides good cosmetic outcomes.

Prognosis of thyroid function after hemithyroidectomy

Identify criteria and create a risk scoring system to predict hypothyroidism after hemithyroidectomy. We have retrospectively studied 216 cases of patients with goiter who had undergone hemithyroidectomy from January 2002 to December 2007 at Vilnius University Hospital Santariškių Klinikos. Patients were divided into two groups according to their thyroid function after hemithyroidectomy: 168 (77.8%) patients’ thyroid function was normal (group A), 48 (22.2%) patients had symptoms of hypothyroidism (group B). The relationship between groups and parameters such as patients’ sex, age, patient’s weight, preoperative serum thyroid-stimulating hormone (TSH) level, weight of the remnant gland, ratio of the remaining thyroid gland weight to patient’s weight was statistically analysed. The patients’ mean age was 41.6 ± 14.1 years in group A and 52.9 ± 13.9 years in group B (p=0.0002). The mean preoperative TSH level was 0.79 ± 0.5 mU/L in group A, compared with 1.42 ± 1.00 mU/L in group B (p= 0.005). The mean ratio of the remaining thyroid gland weight to patient’s weight was 0.102 ± 0.053 g/kg in group A and 0.063 ± 0.027 g/kg in group B (p=0.04). The groups did not establish a significant difference between patients’ sex, patient’s weight or weight of the remaining gland. Patient’s age, preoperative serum TSH level, ratio of the remaining thyroid gland weight to patient’s weight is the main factors of hypothyroidism after hemithyroidectomy. A risk scoring system was created to predict hypothyroidism after hemithyroidectomy before the operation.

Surgical treatment options for aldosteronomas

Introduction Single access retroperitoneoscopic adrenalectomy (SARA) is the most feasible approach for removing aldosteronomas. Aim To analyse the advantages and disadvantages of surgical approaches to treating small adrenal tumours. Material and methods In the period 2002-2011, 31 patients were operated on at Vilnius University Hospital Santariskiu Clinics for aldosteronomas. Adrenalectomies were performed in the lateral laparoscopic (group A, n = 6), the endoscopic retroperitoneal (group B, n = 20), and the single incision laparoscopic surgery (SILS) and SARA (group C, n = 5) approaches. Seventy five percent of patients were operated on by the same surgeon. The duration of adrenalectomies, and intraoperative and postoperative complications were compared. The possibility of minimally invasive adrenalectomies was evaluated. Results According to the patients’ age, body mass index and tumour size, the groups were equal. The average duration of surgery in group A was shorter than in groups B and C (91 ±23 min vs. 118 ±57 min vs. 144 ±88 min). Right laparoscopic adrenalectomy was longer than the left (105 ±26 min vs. 77 ±6 min), whereas right endoscopic retroperitoneal adrenalectomy was shorter than the left (109 ±50 min vs. 126 ±57 min). The best cosmetic view was in group C. The SARA method was converted into the endoscopic retroperitoneal approach and then into the laparoscopic for one patient. There were no intraoperative or postoperative complications. Conclusions Evaluating the minimal invasion of the method, its abilities and simplicity of conversion into another type of endoscopic surgical way, the SARA approach should be the first option for removing aldosteronomas.

Experience of the Treatment of Emphysematous Necrotizing Pancreatitis

Emphysematous pancreatitis is a life-threatening condition that ordinarily requires surgical management. Four cases of emphysematous pancreatitis, including one case with successful medical treatment without any surgical interventions, are described in this article. Case Reports: Four patients had pancreatic necrosis with retroperitoneal and intrapancreatic gas trapping for more than 3 years. Retroperitoneal and intrapancreatic gas trapping was found for all of them during the 1st week of their illness. Two of them underwent immediate surgery after the confirmation of the diagnosis (necrosectomy and open packing), the 3rd patient was operated (necrosectomy and closed lavage) on the 9th day after medical treatment, and the 4th patient recovered after conservative treatment without any surgery. Conclusions: If the patient’s condition is stable, antibiotic treatment without any surgical intervention could be undertaken despite the evidence of pancreatic infection. The general physical condition of the patient is an important factor for choosing a treatment rather than bacteriological or radiological findings of the infection.

Two-stage bilateral laparoscopic adrenalectomy for large pheochromocytomas.

A 66-year-old Lithuanian female patient with a history of hypertension was diagnosed with bilateral adrenal tumors during a routine sonoscopy. Scintigraphy with metaiodobenzylguanidine and computed tomography scan revealed right 130/116/93 mm and left 85/61/53 mm pheochromocytomas. The patient suffered from hypertension with blood pressure over 240/100 mm Hg and heartbeat disturbances. Blood adrenaline levels exceeded the norm 10-fold. After possible spread of tumors was rejected, laparoscopic transperitoneal adrenalectomy was planned in 2 stages, starting on the right then followed by the left side. After preoperative treatment with adrenoblockers, 2-stage bilateral laparoscopic adrenalectomy was performed. 13 cm × 12 cm × 9.5 cm right adrenal and, 3 months later, 8.5 cm × 8 cm × 6 cm left adrenal pheochromocytomas were removed. Histologically – radical extirpation, pheochromocytomas with possible malignant potential. Stable remission of hypertension was achieved postoperatively. Laparoscopic transperitoneal adrenalectomy is a safe and feasible method of treatment of large benign and possible malignant, but noninvasive pheochromocytomas.