Mike Larvin

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.

BACKGROUNDnPancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection.nnnOBJECTIVESnTo determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis.nnnSEARCH STRATEGYnSearches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched.nnnSELECTION CRITERIAnRandomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis.nnnDATA COLLECTION AND ANALYSISnPrimary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem).nnnMAIN RESULTSnSeven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84).nnnAUTHORS CONCLUSIONSnNo benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection

BackgroundElevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer.MethodsPatients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed.ResultsA total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 × 10-9/litre, median lymphocyte count 23.9 × 10-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (≥ 3.5) or low (< 3.5) NLR (p = 0.49).ConclusionPreoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

A review article on gastric volvulus: A challenge to diagnosis and management

Acute gastric volvulus is a life-threatening condition, but its intermittent nature and vague symptoms may make diagnosis difficult. Imaging is usually only diagnostic if carried out when patients are symptomatic. The population affected ranges from paediatric age group to elderly with multiple co-morbidities. Laparoscopic repair is advisable once a diagnosis is reached. This review on gastric volvulus focuses on the diagnostic and management challenges encountered, together with strategies for dealing with them. Lessons have emerged which may assist in dealing with such a rare presentation in future.

Effect of tumor burden and subsequent surgical resection on skeletal muscle mass and protein turnover in colorectal cancer patients

BACKGROUNDnCachexia is a consequence of tumor burden caused by ill-defined catabolic alterations in muscle protein turnover.nnnOBJECTIVEnWe aimed to explore the effect of tumor burden and resection on muscle protein turnover in patients with nonmetastatic colorectal cancer (CRC), which is a surgically curable tumor that induces cachexia.nnnDESIGNnWe recruited the following 2 groups: patients with CRC [n = 13; mean ± SEM age: 66 ± 3 y; BMI (in kg/m(2)): 27.6 ± 1.1] and matched healthy controls (n = 8; age: 71 ± 2 y; BMI: 26.2 ± 1). Control subjects underwent a single study, whereas CRC patients were studied twice before and ~6 wk after surgical resection to assess muscle protein synthesis (MPS), muscle protein breakdown (MPB), and muscle mass by using dual-energy X-ray absorptiometry.nnnRESULTSnLeg muscle mass was lower in CRC patients than in control subjects (6290 ± 456 compared with 7839 ± 617 g; P < 0.05) and had an additional decline after surgery (5840 ± 456 g; P < 0.001). Although postabsorptive MPS was unaffected, catabolic changes with tumor burden included the complete blunting of postprandial MPS (0.038 ± 0.004%/h in the CRC group compared with 0.065 ± 0.006%/h in the control group; P < 0.01) and a trend toward increased MPB under postabsorptive conditions (P = 0.09). Although surgical resection exacerbated muscle atrophy (-7.2%), catabolic changes in protein metabolism had normalized 6 wk after surgery. The recovery in postprandial MPS after surgery was inversely related to the degree of muscle atrophy (r = 0.65, P < 0.01).nnnCONCLUSIONSnCRC patients display reduced postprandial MPS and a trend toward increased MPB, and tumor resection reverses these derangements. With no effective treatment of cancer cachexia, future therapies directed at preserving muscle mass should concentrate on alleviating proteolysis and enhancing anabolic responses to nutrition before surgery while augmenting muscle anabolism after resection.

Large bowel obstruction due to sesame seed bezoar: a case report

We report a case of a 79 year old man with a known benign anastomotic stricture presenting with large bowel obstruction. At laparotomy the obstruction was found to be caused by a large sesame seed bezoar. Seed bezoars are well known to cause impaction in the rectum but have never been previously reported to cause large bowel obstruction. We recommend that patients with known large bowel strictures should be advised not to eat seeds as this could ultimately lead to obstruction, ischaemia or perforation.

An unusual cause of dysuria.

Laparoscopic adjustable gastric band (LAGB) insertion has become an increasingly common treatment for severe obesity worldwide. As a consequence, LAGB complications are reported in increasing numbers and usually present to acute surgical units. This report describes the development of lower abdominal pain and dysuria in a patient who had undergone LAGB surgery 20 months previously. Repeated symptomatic treatment for a possible urinary tract infection in the community setting had been unsuccessful. The cause was found to be a fracture in the tubing connecting the LAGB device with its subcutaneous adjusting port, which was causing persistent bladder irritation. It is recommended that when LAGB patients present with acute lower abdominal pain, consideration should be made as to whether a tubing disconnection has occurred. Such a complication may be visualised by abdominal radiography. Advice can be sought on this and other complications of bariatric surgery by contacting the regional bariatric surgical centre where definitive management would be undertaken.