Goran Imamović

Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre.

AIM To evaluate the efficacy of step-up approach to infected necrotising pancreatitis. METHODS Retrospective analysis of 86 patients treated by step-up approach from 1989 to 2009. Infection was confirmed by examination of aspirated material or by presence of free pancreatic gas at contrast-enhanced computed tomography. Conservative treatment was initially attempted in all patients; percutaneous catheter drainage was performed when conservative therapy failed; surgery was planned only if no clinical improvement was observed. Primary outcome was mortality. RESULTS Fifteen patients (17.4%) were successfully treated with conservative treatment only. Percutaneous catheter drainage was performed in 69 (80.2%). Eight patients (9.3%) died, two at week 1 without drainage or surgery and six after percutaneous catheter drainage and surgery. Eleven patients were converted to surgery (12.8%). Organ failure occurred in 59/86 (68.6%) and multiorgan failure in 25/86 (29.1%). Median (interquartile ranges) hospital stay and catheter dwell times were 13 (9-47) and 15 (7-34) days, respectively. There were 2.61 catheter problems and 1.68 catheter changes per patient. CONCLUSIONS The step-up approach is an effective and safe strategy for the treatment of infected necrotising pancreatitis. Percutaneous drainage can avert the need for surgery in the majority of patients.

Symptomatic Simple Renal Cyst: Comparison of Continuous Negative-Pressure Catheter Drainage and Single-Session Alcohol Sclerotherapy

OBJECTIVE The purpose of this study was to evaluate whether continuous percutaneous catheter drainage with negative pressure yields better results than single-session alcohol sclerotherapy in the management of symptomatic simple renal cysts. SUBJECTS AND METHODS Eighty-five patients with 92 simple renal cysts were randomly assigned to two groups in a prospective controlled trial. One group was treated with sonographically guided continuous catheter drainage with negative pressure and the other group with single-session alcohol sclerotherapy. Patient demographics, clinical characteristics, treatment outcome, and complications were analyzed. RESULTS The initial volume of the cysts did not differ significantly between the groups, but the final volume was significantly smaller in the continuous drainage group (p = 0.026). During the 24-month follow-up period, 37 (40%) of the cysts disappeared completely: 24 (52%) of the 46 cysts in the drainage group and 13 (28%) of the 46 cysts in the sclerotherapy group (p = 0.033). In the sclerotherapy group, the probability of disappearance of the cysts was highly dependent on cyst size, being less for giant cysts (p = 0.01). Cyst size was not a significant factor in probability of disappearance in the drainage group (p = 0.15). The probability of disappearance of giant cysts (volume > 500 mL) differed significantly between the groups (p = 0.009), but there was no difference in probability of disappearance of moderately large cysts (p = 0.16). Three of 14 patients with giant cysts in the drainage group and 10 of 13 such patients in the sclerotherapy group had recurrences that necessitated additional treatment (p = 0.007). They were successfully treated with continuous catheter drainage. CONCLUSION Continuous catheter drainage with negative pressure is more efficient than single-session alcohol sclerotherapy in the management of giant cysts. For moderately large cysts, the two methods have similar results.

Simple renal cysts and arterial hypertension: does their evacuation decrease the blood pressure?

Objective To evaluate the relationships between simple renal cysts and arterial hypertension and whether their evacuation decreases the blood pressure (BP). Methods In a cross-sectional design, we analyzed 184 study participants with cysts and compared hypertensive and nonhypertensive among them. Outcomes were the number, the size and the location of a cyst. In a cross-over design, we first evaluated the change in absolute value of SBP, DBP and mean BP in 62 hypertensive patients who underwent percutaneous evacuation of a cyst and then the decrease of BP as a categorical variable that comprised all study participants. Results There were 55% giant renal cysts among hypertensive and 24% among nonhypertensive patients (P = 0.0001). The prevalence rates of multiple and peripheral cysts in hypertensive and nonhypertensive patients were similar to those of single and perihilar cysts, respectively. Significant differences in SBP, DBP and mean BP were found between pretreatment readings and 3 days, 1 month, 3 months and 6 months after cyst evacuation (P < 0001). The differences were significant in all hypertensive patients (P < 0.001). There were less hypertensive patients 3 days after treatment than before treatment (P < 0.0001). Conclusion An apparent association between the size of a simple renal cyst and hypertension was found, and aspiration of cysts resulted in a reduction of BP. Location and number of cysts were not related to BP.

Percutaneous treatment for symptomatic pancreatic pseudocysts: Long-term results in a single center☆

PURPOSE The aim of the study was to present and evaluate the long-term results of percutaneous catheter drainage (PCD) in the treatment of symptomatic pancreatic pseudocysts (PPC). METHODS We performed a retrospective analysis of 128 patients with 140 PPC treated by PCD from 01/01/1989 to 12/31/2008. All procedures were performed under ultrasound control. Surgical treatment was planned only in patients with failed PCD. The patients were followed up monthly with sonography for 12 months. The primary outcome was conversion rate to surgery. Secondary outcomes were disappearance of PPC, requirement for additional treatment, length of hospital stay, and catheter dwell time. RESULTS During the follow-up, 42 of the 140 cysts (30%) recurred. 19/42 cysts were small and they were followed up without intervention and 23/42 cysts required further intervention. These patients were offered a second attempt but 5 patients declined it and they chose to undergo surgery. The remaining 18 patients underwent second PCD and 10 of them developed recurrence. All of them underwent third PCD and 6 of the 10 patients developed recurrences. Four and 2 of them necessitated surgery and follow-up, respectively. In total, 9 of the 128 patients (7%) underwent surgery during the study period. Medians (interquartile ranges) of hospital stay and catheter dwell time were 19 (14-23) and 23 (15-43) days, respectively. There were no complications related to the procedure. CONCLUSION PCD is a safe and effective management for PPC, with low recurrence rates and complication rate and it can eliminate the need for surgery in majority of patients with PPC.

Comparison of the effects of Puumala and Dobrava viruses on early and long-term renal outcomes in patients with haemorrhagic fever with renal syndrome.

Aim:  The clinical course and outcome of patients with haemorrhagic fever with renal syndrome (HFRS) caused by Puumala (PUUV) and Dobrava viruses (DOBV) were analyzed and whether it left long‐term consequences on kidney function after 10 years was evaluated.

What is the optimal treatment for appendiceal mass formed after acute perforated appendicitis

We read with great interest the editorial article by Meshikhes AWN published in issue 25 of World J Gastroenterol 2011. The article described the advantages of emergency laparoscopic appendectomy compared with interval appendectomy as a new safe treatment modality for the appendiceal mass. The author concluded that the emergency laparoscopic appendectomy was a safe treatment modality for the appendiceal mass, and might prove to be more cost-effective than conservative treatment, with no need for interval appendectomy. However, we would like to highlight certain issues regarding the possibility of percutaneous catheter drainage to successfully treat the appendiceal mass, with no need for appendectomy, too.

Percutaneous drainage without sclerotherapy for benign ovarian cysts.

PURPOSE To evaluate percutaneous short-term catheter drainage in the management of benign ovarian cysts in patients at increased surgical risk. MATERIALS AND METHODS Thirty-eight patients with simple ovarian cysts were treated with drainage of fluid content by catheters until output stopped. All patients were poor candidates for surgery. All procedures were performed under ultrasonographic (US) control and local anesthesia. Cytologic examination was performed in all cases. The patients were followed up monthly with color Doppler US for 12 months. Outcome measure was the recurrence of a cyst. RESULTS During the 12-month follow-up period, 10 of 38 cysts recurred. Seven of the 10 cysts required further intervention, and three were followed up without intervention. Four of the seven patients who required further intervention underwent repeat transabdominal aspiration and three declined repeat aspiration and subsequently underwent surgery. After repeated aspirations, two of four cysts disappeared, one necessitated follow-up only, and one necessitated surgical intervention. Cyst volume (P = .009) and diameter (P = .001) were significantly larger in the cysts that recurred. No evidence of malignancy was reported in the cytologic examination in any patient. No patients developed malignancy during follow-up. No major complications were observed. The hospital stay was 1 day for all patients. The median duration of drainage in the groups with resolved and recurrent cysts was 1 day (interquartile range, 1-1) and 2 days (interquartile range, 1-3), respectively (P = .04). CONCLUSIONS In patients considered poor candidates for open surgery or laparoscopy, percutaneous treatment of ovarian cysts with short-term catheter drainage without sclerotherapy appears to be a safe and effective alternative, with low recurrence rates.

Microalbuminuria as a possible marker of risk of Balkan endemic nephropathy

Aim:  To evaluate whether microalbuminuria could be a marker of early tubular damage in individuals at risk of developing Balkan endemic nephropathy (BEN).

Comments on the article about correlation between computerized tomography and surgery in acute pancreatitis.

We read with great interest the article by Vege et al published in issue 34 of World J Gastroenterol 2010. The article evaluates the ability of contrast-enhanced computerized tomography (CECT) to characterize the nature of peripancreatic collections found at surgery. The results of their study indicate that most of the peripancreatic collections seen on CECT in patients with severe acute pancreatitis who require operative intervention contain necrotic tissue and CECT has a limited role in differentiating various types of collections. However, there are some points that need to be addressed, including data about the stage of acute pancreatitis in which CECT was done and the time span between CECT examination and surgery.

Probability versus Causal Inference in Observational Studies

pends on the research question and proper selection of the confounders used to adjust for the analysis. Their study was designed to test the probability for the outcomes specified while having hemoglobin excursions outside the target range and not to test the association between them [3] , because the analysis was adjusted for hypertension and coronary artery disease which were by definition not confounders in this design being influenced by the hemoglobin level [4–6] . Thus, if one adjusts the analysis for them, the link between hemoglobin excursions and the outcomes tested may be reduced or even canceled out, thereby not revealing the possible effect of an increased hemoglobin level on the outcomes. In this study, hypertension and coronary artery disease were related to the effect of hemoglobin level [5, 6] . This allowed for only prognostic and not etiological inferences to be made because, in the prognostic model, pathophysiology was not an issue but only probabilities for the outcomes specified [3] . Dear Editor We appreciate the reply of Dr. Handelman to our comment [1] on the paper ‘Hospitalization and mortality in hemodialysis patients: association with hemoglobin variability’, published in your journal [2] . In his reply, Dr. Handelman compares the indication of impending problems secondary to having a hemoglobin level below the target range with the fever and elevated white count as indicators of infection as well as with the association between severe edema and congestive heart failure. However, the inferences made quite often in the paper by using wording such as ‘association’, ‘influence’, etc., did not correspond with the methodology applied in their study, which was the major point of our critique, so that no relation exists between the examples specified above by Dr. Handelman. Even infection may not necessarily be associated with an elevated white count, but with a low white count if it is a septic one and severe edema may not be associated with congestive heart failure, but with liver cirrhosis, so that every conclusion dePublished online: June 5, 2014