Basil J. Ammori

Early increase in intestinal permeability in patients with severe acute pancreatitis: Correlation with endotoxemia, organ failure, and mortality

Sepsis accounts for 80% of deaths from acute pancreatitis. This study aimed to investigate early changes in intestinal permeability in patients with acute pancreatitis, and to correlate these changes with subsequent disease severity and endotoxemia. The renal excretion of enterally administered polyethylene glycol (PEG) 3350 and PEG 400 was measured within 72 hours of onset of acute pancreatitis to determine intestinal permeability. Severity was assessed on the basis of APACHE II scores and C-reactive protein measurements. Serum endotoxin and antiendotoxin antibodies were measured on admission. Eight-five patients with acute pancreatitis (mild in 56, severe in 29) and 25 healthy control subjects were studied. Urinary excretion of PEG 3350 (median) was significantly greater in patients who had severe attacks (0.61%) compared to those with mild disease (0.09%) and health control subjects (0.12%) (P <0.0001), as was the permeability index (PEG 3350/400 excretion) (P <0.00001). The permeability index was significantly greater in patients who subsequently developed multiple organ system failure and/or died compared with other severe cases (0.16 vs. 0.04) (P = 0.0005). The excretion of PEG 3350 correlated strongly with endotoxemia (r = 0.8; P = 0.002). Early increased intestinal permeability may play an important role in the pathophysiology of severe acute pancreatitis. Therapies that aim to restore intestinal barrier function may improve outcome.

Intestinal hypoperfusion contributes to gut barrier failure in severe acute pancreatitis.

Intestinal barrier failure and subsequent bacterial translocation have been implicated in the development of organ dysfunction and septic complications associated with severe acute pancreatitis. Splanchnic hypoperfusion and ischemia/reperfusion injury have been postulated as a cause of increased intestinal permeability. The urinary concentration of intestinal fatty acid binding protein (IFABP) has been shown to be a sensitive marker of intestinal ischemia, with increased levels being associated with ischemia/reperfusion. The aim of the current study was to assess the relationship between excretion of IFABP in urine, gut mucosal barrier failure (intestinal hyperpermeability and systemic exposure to endotoxemia), and clinical severity. Patients with a clinical and biochemical diagnosis of acute pancreatitis were studied within 72 hours of onset of pain. Polyethylene glycol probes of 3350 kDa and 400 kDa were administered enterally, and the ratio of the percentage of retrieval of each probe after renal excretion was used as a measure of intestinal macromolecular permeability. Collected urine was also used to determine the IFABP concentration (IFABP-c) and total IFABP (IFABP-t) excreted over the 24-hour period, using an enzyme-linked immun-osorbent assay technique. The systemic inflammatory response was estimated from peak 0 to 72-hour plasma C-reactive protein levels, and systemic exposure to endotoxins was measured using serum IgM en-dotoxin cytoplasmic antibody (EndoCAb) levels. The severity of the attack was assessed on the basis of the Atlanta criteria. Sixty-one patients with acute pancreatitis (severe in 19) and 12 healthy control subjects were studied. Compared to mild attacks, severe attacks were associated with significantly higher urinary IFABP-c (median 1092 pg/ml vs. 84 pg/ml; P < 0.001) and IFABP-t (median 1.14 μg vs. 0.21 |μg; P = 0.003). Furthermore, the control group had significantly lower IFABP-c (median 37 pg/ml; P = 0.029) and IFABP-t (median 0.06 μg; P = 0.005) than patients with mild attacks. IFABP correlated positively with the polyethylene glycol 3350 percentage retrieval (r = 0.50; P < 0.001), CRP (r = 0.51; P < 0.001), and inversely with serum IgM EndoCAb levels (r = —0.32; P = 0.02). The results of this study support the hypothesis that splanchnic hypoperfusion contributes to the loss of intestinal mucosal integrity associated with a severe attack of pancreatitis.

minimally Invasive Approaches to the Management of Pancreatic Pseudocysts : review of the Literature

&NA; Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross‐references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.

Intraoperative cholangiography during laparoscopic cholecystectomy.

AbstractBackground: The routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy remains controversial. Methods: A retrospective review of 950 consecutive laparoscopic cholecystectomies performed during an 8-year period was performed. For the first 2 years, IOC was performed selectively, and thereafter routinely. Results: Attempted in 896 patients, IOC was successful in 734 (82%). Bile duct stones were found in 77 patients (10%), dilated ducts without stones in 47 patients (6%), and anatomic variations in 4 patients (0.5%). There were four (0.4%) minor intraoperative complications related to the IOC, with no consequences for the patients. There were three (0.3%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients. In two of these patients, the structure recognized and catheterized as the cystic duct was revealed by IOC to be the bile duct. Thus IOC prevented extension to a major common bile duct (CBD) injury. Conclusions: Findings show that IOC is a safe technique. Its routine use during laparoscopic cholecystectomy may not prevent bile duct injuries, but it minimizes the extent of the injury so that it can be repaired easily without any consequences for the patient. The prevention of a major bile duct injury makes IOC cost effective.

Laparoscopic cholecystectomy in morbidly obese patients

Background: Morbid obesity is generally regarded as a risk factor for laparoscopic cholecystectomy due to increases in operative time, morbidity, and conversion rate to open cholecystectomy. The aim of this study was to evaluate the feasibility and outcome of laparoscopic cholecystectomy (LC) in morbidly obese patients. Methods: A total of 864 consecutive patients underwent LC at our institution between 1990 and 1997. This series represents a continuing policy of LC for all comers. Data were collected prospectively. There were 659 nonobese (NO: BMI <30 kg/m2), 188 obese (OB: BMI30-40 kg/m2), and 17 morbidly obese patients (MO: BMI >40 kg/m2). Laparoscopic bile duct exploration was performed in 28 (4.2%), nine (4.8%), and one (5.9%) patients, respectively. Results: Obesity and morbid obesity were associated with trends toward an increased conversion rate (2.3% NO; 4.3% OB; 5.9% MO), a longer operative time (median, 80, 85, and 107 mins, respectively), greater postoperative morbidity (4.7%, 5.9%, and 11.8%, respectively), and a reduced ability to obtain cholangiography (86.1%, 80.1%, and 71.4%, respectively). None of these differences, however, were statistically significant (c2 test, p > 0.05). Postoperative hospital stay for LC was similar for all three groups (median, 1 day). Conclusion: LC in morbidly obese patients is a safe procedure, but it may be associated with increased operative difficulty and morbidity, as compared with nonobese and obese patients.

Elective laparoscopic cholecystectomy: preoperative prediction of duration of surgery.

BackgroundEfficient use of operating time has become a key concern. The aim of this study was to determine preoperative factors that can predict extended duration of operating time (>90 min) for laparoscopic cholecystectomy (LC).MethodsData collected prospectively on 827 consecutive patients who underwent elective LC between 1990 and 1997 were analyzed. Factors evaluated included age, gender; body mass index; comorbidity; duration of symptoms; history of jaundice, pancreatitis, or abdominal surgery; dilated common bile duct or thick-walled gallbladder on ultrasound; preoperative endoscopic retrograde cholangiopan-creatography (ERCP) and endoscopic sphincterotomy (ES); and surgeon experience. Univariate and multivariate analyses were performed to identify factors predicting a long operation.ResultsOperating time was longer than 90 min in 276 patients (33%). Predictors of extended operation time were age older than 55 years (odds ratio [OR] = 9.7), preoperative ES (OR = 2.8), and a thick-walled gallbladder on ultrasound (OR = 2.5).ConclusionThese predictors may be useful in planning theater lists and anesthesia management, and in selecting patients for day surgery.

The use of a rapid in situ test in the detection of central venous catheter-related bloodstream infection: a prospective study

BACKGROUND Acridine orange leukocyte cytospin (AOLC) is a highly sensitive and specific test for the detection of catheter-related bloodstream infection (CRBSI). We evaluated the role of the AOLC test in early detection or exclusion of CRBSI and compared the cost of managing patients with suspected CRBSI. METHODS On the day of clinical suspicion of CRBSI, blood samples were obtained from the catheters for the AOLC test, and peripheral blood samples were obtained for quantitative blood cultures. Catheters with positive AOLC results were immediately removed for culture and replaced if necessary. Catheters with negative AOLC tests were left in situ. We compared the catheter lifespan in patients with suspected CRBSI who had positive and negative AOLC tests and calculated the cost of using the AOLC test to prevent indiscriminate catheter removal. RESULTS Fifty patients with suspected CRBSI were tested and prospectively followed up. Catheters were removed in 10 patients (20%) with a positive AOLC test, and CRBSI was confirmed in each case subsequently. Selective removal of catheters based on AOLC tests significantly extended the lifespan of catheters compared with an indiscriminate removal of catheters based on clinical suspicion of CRBSI (median, 24 versus 11 days; p < .0001). The cost of an AOLC test and selective catheter replacement strategy was significantly lower than the cost of routine removal and replacement of catheters (median, pounds sterling 9.53 versus pounds sterling 64.20; p < .0001). CONCLUSION The AOLC test enables a rapid detection of CRBSI, avoids unnecessary removal of catheters, and provides a cost-efficient management approach in patients with suspected CRBSI.

Calcitonin precursors in the prediction of severity of acute pancreatitis on the day of admission

Calcitonin precursors are sensitive markers of inflammation and infection. The aim of this study was to evaluate the role of plasma calcitonin precursor levels on the day of admission in the prediction of severity of acute pancreatitis, and to compare this with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system.

Laparoscopic resection of type I choledochal cyst in an adult and Roux-en-Y hepaticojejunostomy: a case report and literature review.

Choledochal cysts are rare cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts, or both and carry a substantial risk of malignant transformation. Type I choledochal cysts, which involve the entire common hepatic and common bile ducts, represent 80% to 90% of these lesions. We report laparoscopic excision of symptomatic type I choledochal cyst in a 37-year-old woman, and review the literature. Laparoscopic excision of the extrahepatic biliary tree from the hepatic confluence to the anomalous pancreatobiliary junction with en bloc cholecystectomy and reconstruction with a Roux-en-Y hepaticojejunostomy was accomplished. Postoperative recovery was uneventful with a hospital stay of 3 days. She remains well and asymptomatic at 6 months of follow-up. Laparoscopic excision of choledochal cysts may be safely accomplished with a prompt recovery. Further experience with this approach in larger number of patients is justified and long-term follow-up data are needed.

Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal.

Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.