Francisco G. Borobia

A Double-blind, Placebo-controlled Trial of Ciprofloxacin Prophylaxis in Patients with Acute Necrotizing Pancreatitis

BackgroundThe use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial.MethodsProspective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo).ResultsComparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays.ConclusionThe prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

Emergency operations for nondiverticular perforation of the left colon

OBJECTIVE Although diverticulitis is the most common cause of large bowel perforation, other disease may result in left colonic peritonitis. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with different causes of nondiverticular left colonic perforations. PATIENTS AND METHODS From January 1992 to September 2000, 212 surgical patients underwent emergency operation for distal colonic peritonitis. Perforations were caused by diverticulitis in 133 patients (63%) and by a nondiverticular process in 79 (37%). Mortality and morbidity in patients with nondiverticular perforation of the distal large bowel its relationship with the general conditions, the grade and the cause of peritonitis were analysed. Four types of surgical procedures were used. Hartmanns procedure was performed in 40 patients (51%); intraoperative colonic lavage, resection, and primary anastomosis (ICL) in 27 patients (34%); colostomy in 7 (9%); and subtotal colectomy in 5 (6%). RESULTS Perforated neoplasm, the most common cause of peritonitis, was observed in 30 patients, colonic ischemia in 20, iatrogenia in 13, and other causes in 16 patients. One or more complications were observed in 57 patients (72%); among causes of perforation, colonic ischemia was significantly associated with the longest hospital stay and highest mortality. Eighteen patients (23%) died. CONCLUSIONS Left large bowel perforation by nondiverticular disease is associated with high mortality and morbidity. The prognosis of patients is determined by the development of septic shock and colonic ischemia, as underlying disease, may influence patient survival.

Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding

PURPOSE The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding, but it may be possible to identify patients who have a low risk for rebleeding, and can be discharged after a short hospitalization. To examine the effect of an early discharge protocol (length of hospital stay < or =3 days), we conducted a 2-year prospective study in patients with upper gastrointestinal bleeding at low risk for rebleeding, as selected by clinical and endoscopic criteria. METHODS During the first year of the study, patients were managed according to the standard criteria by any of six surgical teams (control period). During the second year, patients were managed by only one surgical team under the early discharge protocol guidelines (study period). RESULTS Overall, 488 of 942 (52%) patients were considered as low risk. Early discharge was achieved in 26 of 230 (11%) patients in the control period and in 191 of 258 (74%) in the study period (P <0.001). Age and number of compensated comorbidities did not affect the rate of early discharge. Length of hospital stay was reduced from (mean +/- SD) 6 +/- 2.7 days (control period) to 3 +/- 2.3 days (study period, P <0.001). No differences were observed in rates of rebleeding, need for surgery, readmission or mortality. By contrast, no differences in lengths of stay were observed during that time period among patients admitted with coronary artery disease, colorectal cancer, or acute pancreatitis. CONCLUSION Most patients with upper gastrointestinal bleeding who are at low risk for rebleeding can be discharged early, leading to important cost savings.

Indicaciones y resultados de la cirugía conservadora en las lesiones localizadas en la cabeza pancreática

Resumen Introduccion La cirugia conservadora de la region duodenopancreatica ha quedado bien establecida en pancreatitis cronica (PC) e incluso algunos grupos han comenzado a utilizar estas tecnicas para tratar tumores benignos y de potencial de malignidad incierto. Ahora bien, la complejidad tecnica de este tipo de intervenciones puede ser superior a la de la duodenopancreatectomia cefalica y las complicaciones, incluso mas frecuentes; por lo tanto, las indicaciones estan en debate. El objetivo de este estudio es evaluar la experiencia acumulada en nuestro centro durante los ultimos anos en el empleo de la cirugia conservadora (CC) de la region duodenopancreatica. Material y metodos Desde 1996 a 2006, hemos realizado CC por afeccion localizada en la region cefalica del pancreas en 24 pacientes. Hemos definido CC como cualquiera de las siguientes tecnicas: pancreatectomia cefalica con preservacion duodenal (PCPD), uncinectomia (UC) y enucleacion de tumores quisticos (EN). Resultados . Realizamos PCPD en 20 (83%) pacientes, UC en 1 (4%) y EN en 3 (13%). Los pacientes fueron intervenidos por PC en 11 casos, cistoadenoma seroso en 4, TPMI en 5 y lesiones de estirpe diversa en los 4 casos restantes. En cuanto a la evolucion postoperatoria, la serie presenta una morbilidad del 54%, sin mortalidad postoperatoria. La estancia hospitalaria postoperatoria mediana fue de 11 (7-43) dias. Conclusiones En definitiva, tras analizar la experiencia obtenida en estos anos, y evidenciar una nula mortalidad con morbilidad aceptable, creemos que la utilizacion de tres tecnicas de preservacion de parenquima pancreatico es util mientras estas sean indicadas con rigor. Estudios posteriores deberian ahondar en la mejoria de la calidad de vida y la repercusion fisiologica segun la tecnica empleada.

Influencia de la aplicación de un protocolo de actuación en el tratamiento de los traumatismos abdominales cerrados

Resumen Introduccion El manejo del traumatismo abdominal cerrado ha variado mucho en los ultimos anos Material y metodos Estudiamos la aplicacion de un protocolo prospectivo a los pacientes con traumatismo abdominal cerrado durante un ano, con el objetivo de evaluar la utilidad del tratamiento no operatorio y su influencia en la morbimortalidad. Todos los pacientes atendidos siguiendo dicho protocolo fueron comparados con un grupo de pacientes previo Resultados Durante el periodo de estudio prospectivo, 65 pacientes fueron ingresados con traumatismo abdominal cerrado (grupo prospectivo [P]). Durante el periodo previo fueron atendidos 77 pacientes (grupo retrospectivo [R]). No hubo diferencias significativas entre ambos grupos en cuanto al sexo, la edad, la escala HIS (Haemodynamic Injury Scale) o el mecanismo de lesion. El 55% de los pacientes del grupo R fue intervenido, mientras que en el grupo P se intervino al 25% (p = 0,0005). Entre los pacientes con lesion esplenica, en el grupo R fue intervenido el 85%, mientras que en el grupo P solo el 50% (p = 0,03). Entre los pacientes con lesiones hepaticas fue intervenido el 70% en el periodo R y solo el 16% en el periodo P (p = 0,05). No hubo diferencias significativas entre los grupos R y P en la estancia hospitalaria, la estancia en UCI, la transfusion y la mortalidad hospitalaria Conclusiones La aplicacion de un protocolo de manejo de los pacientes con traumatismo abdominal cerrado permite el tratamiento no operatorio en la mayoria de los casos sin aumentar la morbimortalidad, la estancia hospitalaria o los requerimientos transfusionales, evitando la morbilidad ocasionada por la propia cirugia

Neoplasias quísticas del páncreas. Manejo diagnóstico y terapéutico

El manejo de las lesiones quisticas del pancreas interesa tanto al cirujano general y pancreatico como a los especialistas en otras disciplinas: gastroenterologia, medicina interna, endoscopia, radiologia, anatomia patologica, etc. La mayoria de estas lesiones son seudoquistes inflamatorios. Las neoplasias quisticas suponen solo un 10% del total de las lesiones quisticas del pancreas y un 1% de los tumores pancreaticos. El diagnostico preoperatorio es crucial, dadas las diferencias en la historia natural del espectro de las lesiones: benignas, malignas y borderline. El cistadenoma seroso es una lesion benigna que no precisa reseccion quirurgica, salvo cuando es sintomatica. Las neoplasias mucinosas son lesions premalignas que requieren mayoritariamente reseccion pancreatica. A pesar de los avances en las tecnicas de imagen, el diagnostico definitivo se establece unicamente tras el estudio histologico de la pieza de reseccion. El riesgo que comporta la cirugia pancreatica es un problema asociado al manejo apropiado de estos pacientes.

Hemosuccus pancreático originado en la arteria gástrica izquierda: causa infrecuente de hemorragia digestiva

We present the case of a 61-year-old male with a history of chronic alcohol-related pancreatitis who consulted for melena. Abdominal CT angiography and arteriography showed evidence of a pseudoaneurysm of the left gastric artery (upper arrows) with active bleeding towards the pancreatic duct (lower arrow) (Fig. 1). Arteriography with coil embolization of the afferent and efferent branches completely excluded the pseudoaneurysm. The patient’s clinical evolution was correct. Hemosuccus pancreaticus occurring after the rupture of a pseudoaneurysm of a peripancreatic artery towards the pancreatic duct is a potential cause of gastrointestinal bleeding in cases of acute or chronic pancreatitis. c i r e s p . 2 0 1 9 ; 9 7 ( 2 ) : 1 1 0

Effect of the platelet-activating factor antagonist BN-52021 on liver preservation (4°): experimental study in isolated reperfused rat liver model ☆

PRESERVATION INJURY is a major contributor to primary allograft dysfunction and failure after liver transplantation. Several studies have shown that cold ischemia (CI) can damage the sinusoidal liver cells. During this process many inflamatory mediators are released locally and to the blood stream. The damaged endothelial cells produce the activation and adhesion of leukocytes. Finally, the infiltration of polymorphonuclear cells increases the cold ischemic lesion. Platelet-activating factor (PAF) is an inflammatory mediator produced by many cell types. It has been implicated in the microcirculatory failure after cold and warm ischemia. PAF antagonist BN-52021 is a natural compound extracted from ginkgo-biloba tree. Its beneficial effect has been reported in ischemia reperfusion injury of many organs. The objective of our study was to demonstrate that the PAF antagonist BN-52021 can attenuate the preservation injury. The isolated perfused rat liver model was employed for reperfusion evaluation.