Gustavo Kohan

Early Endoscopic Intervention Versus Early Conservative Management in Patients With Acute Gallstone Pancreatitis and Biliopancreatic Obstruction: A Randomized Clinical Trial

Objective:To test the hypothesis that early endoscopic intervention, performed on patients with acute gallstone pancreatitis and biliopancreatic obstruction, reduces systemic and local inflammation. Summary Background Data:The role of early endoscopic intervention, in the treatment of acute gallstone pancreatitis, remains controversial. Previous randomized trials have not focused on the subgroup of patients with clinical evidence of biliopancreatic obstruction. Methods:This single-center randomized clinical trial was performed between May 2000 and September 2005. Of 238 patients, admitted within 48 hours after the onset of acute gallstone pancreatitis, 103 with a distal bile duct measuring ≥8 mm combined with a total serum bilirubin ≥1.20 mg/dL, were randomized to receive either endoscopic retrograde cholangiopancreatography followed by endoscopic papillotomy for bile duct stones (EEI, n = 51) or early conservative management (ECM, n = 52). Patients with clinical evidence of coexisting acute cholangitis were excluded. Outcome measures included changes in organ failure score and computed tomography (CT) severity index during the first week after admission, incidence of local complications, and overall morbidity and mortality. Results:The incidence of bile duct stones at EEI was 72% and 40% of patients in the ECM group had persisting bile duct stones at elective biliary surgery. No significant differences were found between the EEI and ECM groups regarding changes in mean organ failure score (P = 0.87), mean CT severity index (P = 0.88), incidence of local complications (6% vs. 6%, P = 0.99), overall morbidity (21% vs. 18%, P = 0.80), and mortality (6% vs. 2%, P = 1). Conclusions:The present study failed to provide evidence that early endoscopic intervention reduces systemic and local inflammation in patients with acute gallstone pancreatitis and biliopancreatic obstruction. If acute cholangitis can be safely excluded, early endoscopic intervention is not mandatory and should not be considered a standard indication.

Computed tomographic prognostic factors for predicting local complications in patients with pancreatic necrosis.

This prospective study aimed at evaluating dynamic computed tomography (CT) as a prognostic indicator of local complications in patients with pancreatic necrosis. Methods: We analyze the relationship between the anatomic pattern of pancreatic necrosis at dynamic CT (pancreatic necrosis, peripancreatic necrosis, and transparenchymal necrosis) and the development of local complications (infected pancreatic necrosis and pseudocyst). Results: One hundred thirty-eight patients were included in the study. Nine patients were excluded, and 86 required surgery. Average time from the onset of symptoms to dynamic CT was 8.3 days. Multivariate analysis identified the following prognostic factors for local complications: (1) extent of pancreatic necrosis (odds ratio [OR], 7.32; 95% confidence interval [CI], 1.32-23.76; P = 0.015) and presence of peripancreatic necrosis (OR, 37.32; 95% CI, 3.77-369.38; P = 0.002) were useful to predict the development of infected pancreatic necrosis; and (2) transparenchymal necrosis with upstream viable (enhancing) pancreas (OR, 36.22; 95% CI, 3.18-412.36; P = 0.004) and no peripancreatic necrosis (OR, 0.016; 95% CI, 0.004-0.62; P < 0.001) were associated with pseudocyst development. Conclusions: Dynamic CT prognostic factors useful to predict local complications in patients with pancreatic necrosis were the extent of pancreatic necrosis, presence of peripancreatic necrosis, and the finding of transparenchymal necrosis with upstream viable (enhancing) pancreas.

Treatment of Acute Pancreatic Pseudocysts After Severe Acute Pancreatitis

Treatment of acute pancreatic pseudocysts (APP) after an episode of severe acute pancreatitis (SAP) remains controversial. Both population heterogeneity and limited numbers of patients in most series prevent a proper analysis of therapeutic results. The study design is a case series of a large, tertiary referral hospital in the surgical treatment of patients with APP after SAP. An institutional treatment algorithm was used to triage patients with complicated APP and organ failure based on Sequential Organ Failure Assessment scores to temporizing percutaneous or endoscopic drainage to control sepsis and improve their clinical condition before definitive surgical management. Over a 10-year period of study (December 1995 to 2005), 73 patients with APP after an episode of SAP were treated, 43 patients (59%) developed complications (infection 74.4%, perforation 21%, and bleeding 4.6%) and qualified for our treatment algorithm. Percutaneous/endoscopic drainage was successful in controlling sepsis in 11 of 13 patients (85%) with severe organ failure and allowed all patients to undergo definitive surgical management. The morbidity (7 vs 44.1%, P = 0.005) and mortality rates (0 vs 19%, P = 0.04) were significantly higher in complicated vs uncomplicated APP. Acute pancreatic pseudocysts after SAP are unpredictable and have a high incidence of complications. Once complications develop, there is a significantly higher morbidity and mortality rate. In complicated APP with severe organ failure, percutaneous/endoscopic drainage is useful in controlling sepsis and allowing definitive surgical management.

Closure of a contained open abdomen using a bipedicled myofascial oblique rectus abdominis flap technique

A contained open abdomen is commonly used during damage control laparotomy and consists of the temporary coverage of the abdomen for protection of the viscera and reduction of intra-abdominal pressure. Definitive closure of a contained open abdomen is technically difficult due to the inability to obtain primary fascial suture. The insertion of a prosthetic mesh can be complicated with enterocutaneous fistula, and other definitive closure techniques need several surgical procedures. We describe a low cost technique that allows definitive closure of large abdominal wall defects avoiding the risk of intestinal fistula.

La contemporización biliar percutánea como estrategia en el tratamiento de la lesión quirúrgica de la vía biliar

Background: Percutaneous biliary drainage (PTBD) has been used to treat surgical bile duct injuries and as an adjunct to repair surgery. Objective: To present the results of PTDB in a consecutive series of patients with surgical injuries or sequelae of surgical repairs of the bile duct. Material and methods: Patients initially treated with PTBD were analyzed. Strasberg classification was used and recorded: type of operation, surgical approach, number of reoperations, biliary repair attempts and clinical presentation. In patients with bilioenteric continuity, percutaneous biliary treatment was the first option. PTBD was evaluated in the pre, intra and postoperative period and in the pre dilatation period. Results: At the Hospital Argerich, from 2000 to 2014, 76 patients were included, 68.4% women and 97% post cholecystectomy. The lesions were Type E2 to E5 in 77% of cases. The percentage of patients with controlled symptoms before surgery or percutaneous dilatation was: jaundice 59%, cholestasis 5%, cholangitis 91%, biliary fistula 87%, pruritus 90%, withdrawal hepaticostoma or T-Kehr 91%. In 13 of 16 patients with external biliary fistula, the catheter could be internalized to abdominal cavity. In 70% of 52 operated patients, the catheter facilitated the identification of the proximal biliary duct. In the postoperative period, there were no biliary fistulas of the bilioenteric anastomoses and 3 patients with residual biliary stenosis and 2 with isolated biliary segments were detected and treated. Conclusion: PTBD is helpful in the pre, intra and postoperative treatment of patients with surgical bile duct injuries. Palabras clave: lesión quirúrgica vía bliar, procedimientos percutáneos biliares.