Gerardo Mangiante

Lactobacillus plantarum Reduces Infection of Pancreatic Necrosis in Experimental Acute Pancreatitis

Background: Infection is the commonest cause of death in acute pancreatitis. Early reduction of commensal flora (particularly Lactobacillus species) and, at the same time, overgrowth of Enterobacteriaceae, especially Escherichia coli, have recently been described during acute pancreatitis. Lactobacillus plantarum has been shown to be effective in reducing the egress of endotoxin and microbial translocation in several experimental models such as chemically induced hepatitis and ulcerative colitis. Aim: The aim of the study was to determine whether L. plantarum 299v (Lp 299v) is capable of effectively reducing microbial translocation in experimental pancreatitis. Methods: Acute pancreatitis was induced by isolation and ligation of the biliopancreatic duct in Lewis rats weighing 250–350 g. The animals were divided into 3 groups: group A, sham operation; group B, induction of pancreatitis and no further treatment, and group C, induction of pancreatitis + daily administration by gavage of a 5-ml/day suspension of Lp 299v at 0.5–1.0 × 109 bacteria/ml for 8 days, 4 days before and 4 days after induction of pancreatitis. All animals were sacrificed after 96 h. Histological studies and microbiological analyses were performed. Results: At sacrifice, 40/55 animals showed signs of severe pancreatitis. Since acute pancreatitis was the specific disease investigated, only these animals were subjected to further study. In group B, we found pathogenic micro-organisms in the mesenteric lymph nodes in 14/20 animals and in the pancreatic tissue in 10/20. The bacterial flora consisted predominantly of E. coli, Enterococcus faecalis, Pseudomonas and Proteus species. In contrast, when the animals were kept under an ’umbrella’ of Lp 299v, growth of E. faecalis or E. coli were detected only in 4/20 mesenteric lymph node cultures and in 3/20 pancreatic tissue cultures. Conclusions:Lp 299v is effective in reducing microbial translocation in experimental pancreatitis. Treatment with probiotic bacteria seems to be a promising alternative to antibiotic therapy.

Contribution of CT to characterization of focal nodular hyperplasia of the liver

Our personal series of 20 cases of focal nodular hyperplasia (FNH) of the liver is presented. All lesions were studied with computed tomography (CT), 16 of which with surgical control. Retrospective evaluation of the CT features of the identified FNH, along with those of five hepatocellular adenomas (HCA) and 30 hepatocellular carcinomas (HCC), allowed the definition of specific patterns leading to a correct characterization of FNH in 78% of cases. This greatly reduced the diagnostic errors, with the sole exception of patients with fatty liver in whom nuclear medicine may eventually provide a correct characterization. Fine-needle biopsy is thus only necessary in the dubious cases. A precise diagnostic workup of FNH is necessary, since it may avoid the surgical intervention.

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800±490 ml vs. 700±586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16±8.1 days vs 17±13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360±68.9 minutes vs. 330±66.9 minutes,P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

Experience on complex incisional hernia treatment in septic patients

Diverting loop ileostomy is a standard procedure during low anterior rectal resection for cancer to reduce clinically apparent anastomotic leakages. The closure of those ileostomies can be complicated by wound infection or incisional hernia with a reported hernia rate ranging from 0 to 48%. This analysis investigates the incidence of incisional hernias following ileostomy closure with consideration of underlying risk factors. All patients undergoing ileostomy closure between 112009 and 12/2013 were included in this investigation. Clinical examination and routine abdominal CT scans performed for oncologic follow-up were used to evaluate the incidence of incisional hernias at the stoma site. Possible risk factors like chemotherapy and wound infection were assessed. A total of 77 ileostomy closures were performed in 77 patients (23 female, 54 male). All patients received the ileostomy during a low anterior rectal resection for rectal cancer. The median follow-up was 12 months (1-31 months). All patients underwent a routine CT scan of the abdomen for oncologic follow-up. All patients were treated with neoadjuvante radiochemotherapy prior to resection of the tumor, 27 (35%) received adjuvant chemotherapy additionally. The median time interval between stoma creation and closure was 12 weeks (1-25 months). A postoperative wound infection was reported for 8 (10.4%) patients. Only 1 (1.3%) incisional hernia was diagnosed in the CT scan of these patients. Neither wound infection nor chemotherapy has been shown to be a risk factor for incisional hernia. The incidence of incisional hernias at the stoma site following ileostomy closure is very low in our series. Neither any kind of chemotherapy nor wound infection has been shown to be a risk factor in these patients. Longer observation of those patients will be necessary to evaluate the rate of incisional hernias.

Carcinoma of Thoracic and Cervical Esophagus: Technical Notes

Historically, surgeons have controversially discussed the merits of one surgical approach over another. According to Orringer, for example, every patient in need of an esophagectomy for malignant disease is a potential candidate for trans-hiatal esophagectomy (THE). Other surgeons claim the superiority of the trans-thoracic approach (TTE), performed in two or three phases depending on whether the tumor is above or below the carina. TTE has the advantage of a more radical resection and lymphadenectomy. The majority of the published trials report a higher incidence of anastomotic leakage and vocal cord paralysis after THE, while TTE more often results in pulmonary complications and greater peri-operative blood loss [1, 2]. The most recent Dutch randomized trial, dealing only with adenocarcinoma and already discussed in previous chapters, showed a higher complication rate in the TTE group while no difference was reported in mortality; additionally, a survival advantage was noted for patients with tumors located in the distal esophagus [3]. In a recent international survey, 52% of the surgeons were found to prefer TTE and 26% THE [4].

Proximal Gastrectomy: Technical Notes

A new technique for recostruction after proximal gastrectomy for EGJ adenocarcinoma (Siewert II with < 2 cm esophageal invasion and Siewert III) and upper-third early gastric cancer is presented. Since January 2000, 50 patients have been treated with this new technique. Postoperative morbidity and mortality were respectively, 25% and 2%, with a leak rate of 8%. At 6 and 12 months, reflux rates were 30% and 33% and stricture rates 20% and 6.7%, respectively. The data show that this technique is feasible, with good results in terms of morbidity and mortality as well as functional outcome.