Edgar D. Sy

Role of Somatostatin in the Prevention of Pancreatic Stump-related Morbidity following Elective Pancreaticoduodenectomy in High-risk Patients and Elimination of Surgeon-related Factors: Prospective, Randomized, Controlled Trial

A prospective, randomized, controlled trial was performed to determine the efficacy of somatostatin in the prevention of pancreatic stump-related complications with elimination of surgeon-related factors in high-risk patients undergoing panceaticoduodenectomy. From August 1997 to December 2000, 54 patients, 28 men and 26 women, with age ranged from 32 to 89 years, were randomly assigned to somatostatin group (n = 27) or placebo group (n = 27). Ninety-four percent of the patients had pancreatic and periampullary lesions; 6% had secondary lesion involving the duodenum such as local recurrent colon carcinoma and renal cell carcinoma. These patients received either standard pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy. An experienced surgeon performed all operations in same fashion to minimize the surgical factor. A transanastomotic tube was inserted into the pancreatic duct for diversion of pancreatic juice in the pancreaticojejunostomy for a 3-weeks period postoperatively. Intravenous infusion of somatostatin was given at a dose of 250μg/hr in the somastotatin group and normal saline was given to the control group for 7 days postoperatively. There was one perioperative death in each group, resulting in a 3.7% mortality rate. In the somastotatin group, as compared to the placebo group, the incidence of overall morbidity and pancreatic stump related complications were significantly lower with a mean decrease of 50% pancreatic juice output and a slightly shorter duration of hospital stays. In conclusion, after excluding surgeon related factor, prophylactic use of somatostatin reduces the incidence and severity of pancreatic stump related complications in high-risk patients having pancreaticoduodenectomy via decreased secretion of pancreatic exocrine.

Early presumptive therapy with fluconazole for occult Candida infection after gastrointestinal surgery.

The objective of this retrospective comparative study was to improve the outcome of patients with suspected occult Candida infection after gastrointestinal surgery by early presumptive therapy. It was conducted in the National Cheng Kung University Hospital in Taiwan. A total of 36 patients with prolonged ileus with fever after gastrointestinal tract surgery between January 1995 and December 2002 were examined for two time periods: those treated before and those treated after January 1999. One set of patients did not receive early presumptive therapy (EPT) until Candida infection was confirmed, and they were designated EPT(−). Another group of patients with suspected occult Candida infection received EPT and were designated EPT(+). Fluconazole, 400 mg/day, was given as EPT. Urine, wound, intraperitoneal drainage, and blood specimens were obtained from patients for fungus culture before starting treatment and weekly until symptoms subsided. The primary endpoints were the frequency of candidiasis and the persistence of candidemia; the secondary endpoint was the efficiency of EPT in the clinical outcome. There was no difference in Candida peritonitis, wound colonization, or urine colonization in the two treatment groups. Candida albicans accounted for 87.5%% of the isolated Candida species: 84.6%% in the EPT(+) group and 89.5%% in the EPT(−) group. In the EPT(+) group, the positive blood culture rate was 66.7%%. The fever subsided rapidly in 17 patients (94%%), the hospital stay and intensive care unit stay were shorter, and the mortality decreased significantly: 11%% vs. 78%%, P < 0.001. Persistent gastrointestinal ileus was the main cause of breakthrough candidemia. We concluded that EPT with fluconazole improves the prognosis of patients with occult Candida infection after gastrointestinal surgery. Surgical intervention was required in patients with breakthrough candidemia.

Effects of somatostatin prophylaxis after pylorus-preserving pancreaticoduodenectomy: increased delayed gastric emptying and reduced plasma motilin.

Somatostatin inhibits gastroenteropancreatic exocrine secretion and is often used after pancreaticoduodenectomy to reduce pancreatic secretion to minimize tissue damage and pancreatic stump complications. Because our earlier clinical work saw a major increase in delayed gastric emptying (DGE) with somatostatin prophylaxis after pylorus-preserving pancreaticoduodenectomy (PPPD), this small-group study was designed to confirm or disprove that observation. From August 1997 to December 2000, a total of 23 post-PPPD patients were randomized to receive somatostatin prophylaxis [somatostain (+)] (n = 11) or not [somatostatin] (−) (n = 12). The incidence of DGE, scintographic solid-phase emptying results on day 14 postoperatively, and sequential fasting plasma motilin levels were compared, as motilin levels are related to both gastric motility and somatostatin levels. The somatostatin(+) group exhibited greatly increased patient complaints of DGE: 9 of 11 (82%) versus 3 of 12 (25%) in the somatostatin(−) group. Radiologic scintography showed somatostatin prophylaxis prolonged the half-time (T1/2) of solid-phase emptying: 144.5 ± 51.4 minutes for somatostatin(+) versus 89.0 ± 59.9 minutes for somatostatin(−) (p < 0.001). Comparing pre-PPPD and post-PPPD plasma motilin levels prior to somatostatin infusion, motilin decreased 80% in reaction to the surgery. For somatostatin(−) patients, motilin levels oscillated, or “rang,” postoperatively, reaching a higher level on day 3, declined to a new record minimum on day 7, and by day 21 were 50% of the original and the slope of the recovery curve was increasing well. In somatostatin(+) patients the same ringing pattern was observed but decreased with motilin levels 30% to 70% lower than in the somatostatin(−) patients. By day 21 somatostatin(+) motilin levels were recovering but still only 20% original levels, and the slope of the recovery curve was not optimistic. On postoperative day 14 the plasma motilin levels (below approximately 6 bg/ml) correlated strongly with DGE for both groups. Despite the small sample size, the results indicated that (1) somatostatin prophylaxis significantly decreases fasting plasma motilin; (2) somatostatin prophylaxis produces lingering suppression of plasma motilin; (3) PPPD surgery itself significantly reduces fasting motilin levels with recovery to 50% normal at day 21; (4) the mechanism of somatostatin-induced DGE seems related to reduced fasting plasma motilin levels.

Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer.

The incidence of postoperative fungal infection is increasing and the gastrointestinal tract is the major source, but antifungal therapy in perforated peptic ulcer (PPU) is still controversial. The aim of this study was to determine the significance of intraoperative peritoneal fluid culture of fungus and establish the indications for treatment.

Annular Pancreas with Obstructive Jaundice : Beware of Underlying Neoplasm

Introduction Annular pancreas is a rare congenital abnormality, and in adult patients it presents with clinical features that differ from those seen in newborns. Features in the adult patient include peptic ulceration, duodenal obstruction, acute pancreatitis, and obstructive jaundice. Treatment strategies for annular pancreas with obstructive jaundice remain controversial. Aim To present three cases involving adult patients with annular pancreas and obstructive jaundice, due to carcinoma of the ampulla of Vater in two patients and chronic pancreatitis in the third. Methodology and Results Pancreaticoduodenectomy was performed on all patients, and the postoperative courses were uneventful. Conclusion Our experience suggests that for adult patients with annular pancreas presenting with obstructive jaundice, it is necessary to consider the possibility of associated or coexisting periampullary malignancy.

Impact of Etiologic Factors and APACHE II and POSSUM Scores in Management and Clinical Outcome of Acute Intestinal Ischemic Disorders after Surgical Treatment

BackgroundAcute intestinal ischemic disorder (AIID) is an uncommon vascular disease with high mortality. According to etiology, it can be categorized into three groups: arterial occlusive mesenteric ischemia (AOMI), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI). This study analyzes the effect of classification on surgical outcome.Patients and MethodsAll AIID patients who underwent operative treatment at National Cheng Kung University Hospital between January 1989 and August 2003 were enrolled in this study. Preoperative information on these patients was compared to find predictors of outcome.ResultsData from 77 patients (49 men and 28 women, median age 70 years) were analyzed. The etiology was AOMI in 30 patients, MVT in 19 patients, and NOMI in 28 patients. Median age was younger in MVT (54 years) than in AOMI (70 years) or NOMI (72 years). In addition, MVT usually involved the jejunum (74%, versus 31% in AOMI and 46% in NOMI), whereas both AOMI and NOMI involved ileum and colon. The patients with AOMI had shorter duration of symptoms and higher ratio of underlying hypertension than those with MVT. The overall mortality rate was 53.2% (41/77). The day 1 and day 30 mortality were 0% and 10.5% in MVT, 16.7% and 30% in AOMI, and 42.9% and 67.9% in NOMI, respectively (P < 0.05). Both the etiology and the APACHE II scores were significant risk factors for day 30 and long-term mortality. The patients with NOMI had higher POSSUM physiologic scores than patients with MVT. The P-POSSUM regression equation can accurately predict mortality.ConclusionsPatients with MVT had a more favorable prognosis, whereas those with NOMI had the worst outlook. The APACHE II and POSSUM scoring systems are useful in predicting the clinical outcome. Early diagnosis and classification of AIID patients are useful for aggressive treatment to improve the clinical outcome.

The influence of spleen size on liver regeneration after major hepatectomy in normal and early cirrhotic liver

Abstract: Background/Purpose: The relationship between liver regeneration and spleen size after major hepatectomy in normal and cirrhotic liver was studied by single photon emission computed tomography (SPECT).

Nested Polymerase Chain Reaction in the Diagnosis of Negative Ziehl-Neelsen Stained Mycobacterium Tuberculosis Fistula-in-Ano

AbstractPURPOSE: Mycobacterium is one of the causes of granulomatous diseases within the anorectal region. Early diagnosis of Mycobacterium infection is important before the use of antituberculosis chemotherapy. Clinical diagnosis is usually dependent on microscopic detection using Ziehl-Neelsen stain and mycobacterial culture, but the sensitivity and specificity of these two methods are low. In this study nested polymerase chain reaction was used to detect mycobacterial infection in anal fistulas. METHODS: Paraffin-embedded specimens from three patients and discharge from one patient were used. DNA extraction was performed using phenol/chloroform techniques. IS6110-based nested polymerase chain reaction, yielding a 259-bp amplicon, for the diagnosis of Mycobacterium infection was done to facilitate treatment. RESULTS: Four cases of suspected Mycobacterium tuberculosis fistulas-in-ano presented with persistent fistula or unhealed wound. Histopathologic examination revealed granulomatous inflammation with failed microscopic detection of acid-fast bacilli using Ziehl-Neelsen stain. Nested polymerase chain reaction confirmed the presence of M. tuberculosis in all cases. The anal lesions healed rapidly following a course of antituberculosis therapy. CONCLUSION: Molecular diagnosis of M. tuberculosis fistula-in-ano by nested polymerase chain reaction is useful for clinically highly suspected Mycobacterium infection despite a negative Ziehl-Neelsen stain.

Nested polymerase chain reaction in the diagnosis of negative Ziehl-Neelsen stained Mycobacterium tuberculosis fistula-in-ano: report of four cases.

PURPOSE Mycobacterium is one of the causes of granulomatous diseases within the anorectal region. Early diagnosis of Mycobacterium infection is important before the use of antituberculosis chemotherapy. Clinical diagnosis is usually dependent on microscopic detection using Ziehl-Neelsen stain and mycobacterial culture, but the sensitivity and specificity of these two methods are low. In this study nested polymerase chain reaction was used to detect mycobacterial infection in anal fistulas. METHODS Paraffin-embedded specimens from three patients and discharge from one patient were used. DNA extraction was performed using phenol/chloroform techniques. IS6110-based nested polymerase chain reaction, yielding a 259-bp amplicon, for the diagnosis of Mycobacterium infection was done to facilitate treatment. RESULTS Four cases of suspected Mycobacterium tuberculosis fistulas-in-ano presented with persistent fistula or unhealed wound. Histopathologic examination revealed granulomatous inflammation with failed microscopic detection of acid-fast bacilli using Ziehl-Neelsen stain. Nested polymerase chain reaction confirmed the presence of M. tuberculosis in all cases. The anal lesions healed rapidly following a course of antituberculosis therapy. CONCLUSION Molecular diagnosis of M. tuberculosis fistula-in-ano by nested polymerase chain reaction is useful for clinically highly suspected Mycobacterium infection despite a negative Ziehl-Neelsen stain.

Predictors for resectability and survival in locally advanced pancreatic cancer after gemcitabine-based neoadjuvant therapy

BackgroundTo evaluate the predictors for resectability and survival of patients with locally advanced pancreatic cancer (LAPC) treated with gemcitabine-based neoadjuvant therapy (GBNAT).MethodsBetween May 2003 and Dec 2009, 41 tissue-proved LAPC were treated with GBNAT. The location of pancreatic cancer in the head, body and tail was 17, 18 and 6 patients respectively. The treatment response was evaluated by RECIST criteria. Surgical exploration was based on the response and the clear plan between tumor and celiac artery/superior mesentery artery. Kaplan–Meier analysis and Cox Model were used to calculate the resectability and survival rates.ResultsFinally, 25 patients received chemotherapy (CT) and 16 patients received concurrent chemoradiation therapy (CRT). The response rate was 51% (21 patients), 2 CR (1 in CT and 1 in CRT) and 19 PR (10 in CT and 9 in CRT). 20 patients (48.8%) were assessed as surgically resectable, in which 17 (41.5%) underwent successful resection with a 17.6% positive-margin rate and 3 failed explorations were pancreatic head cancer for dense adhesion. Two pancreatic neck cancer turned fibrosis only. Patients with surgical intervention had significant actuarial overall survival. Tumor location and post-GBNAT CA199 < 152 were predictors for resectability. Post-GBNAT CA-199 < 152 and post-GBNAT CA-125 < 32.8 were predictors for longer disease progression-free survival. Pre-GBNAT CA-199 < 294, post-GBNAT CA-125 < 32.8, and post-op CEA < 6 were predictors for longer overall survival.ConclusionTumor location and post-GBNAT CA199 < 152 are predictors for resectability while pre-GBNAT CA-199 < 294, post-GBNAT CA-125 < 32.8, post-GBNAT CA-199 < 152 and post-op CEA < 6 are survival predictors in LAPC patients with GBNAT.