Outi Lindström

Treatment of Abdominal Compartment Syndrome with Subcutaneous Anterior Abdominal Fasciotomy in Severe Acute Pancreatitis

BackgroundManaging the abdominal compartment syndrome associated with severe acute pancreatitis by the open abdomen method is associated with considerable morbidity and resource utilization.MethodsA technique of subcutaneous anterior abdominal fasciotomy is described for the first time in two patients with severe acute pancreatitis.ResultsFollowing the procedure, the intra-abdominal pressure decreased from 30 mmHg immediately to 23 mmHg and to a sustained level of 12–14 mmHg in the first patient, and from 35 mmHg immediately to 23 mmHg and to a sustained level of 14–19 mmHg in the second patient.ConclusionsThe subcutaneous anterior abdominal fasciotomy is a promising method for safe and effective abdominal decompression with sustained effect and avoiding the morbidity associated with the alternative open abdomen techniques.

Risk factors for complications of ERCP in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiographic pancreatography (ERCP) is the most accurate technique for surveillance of patients with primary sclerosing cholangitis (PSC). Our aim was to evaluate risk factors for complications of ERCP in patients with PSC. PATIENTS AND METHODS In 2007 - 2009 we performed 441 ERCPs in patients with PSC. The primary tools for ERCP were a guide wire and papillotomy knife to gain access into the biliary duct. If the primary cannulation failed, and the wire went only into the pancreatic duct, pancreatic sphincterotomy was performed. If necessary, a further oblique cut with a needle knife was done in order to expose the biliary duct. RESULTS Primary cannulation was successful in 389 patients (88.2 %). Of these, 147 (37.8 %) had had biliary sphincterotomy performed previously. In the group with failed primary cannulation, access into the biliary duct was achieved after pancreatic sphincterotomy in 52 patients. In 11 of these, a further cut with a needle knife was performed. Post-ERCP pancreatitis (PEP) was diagnosed in 31 patients (7.0 %). Factors predicting PEP were female sex (odds ratio [OR] 2.6, P = 0.015) and a guide wire in the pancreatic duct (OR 8.2, P < 0.01). Previous biliary sphincterotomy was a protective factor (OR 0.28, P = 0.02). The risk of PEP increased with the number of times the wire accidentally passed into the pancreatic duct (P < 0.001). Cholangitis developed in 6 patients (1.4 %). CONCLUSIONS In patients with PSC the incidence of ERCP complications remained relatively low. The complication risk increased with the complexity of cannulation. In a patient with PSC in whom follow-up ERCP is planned, biliary sphincterotomy should be considered, as it may protect against PEP.

Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study

BACKGROUND Deep sedation with propofol and an opioid is commonly used for ERCP but is associated with increased risk and may require the presence of an anesthesiologist. Delivery of propofol and a short-acting, potent opioid analgesic remifentanil by patients to themselves (patient-controlled sedation, PCS) could be another option. Comparative studies with propofol PCS for ERCP are lacking. OBJECTIVE To compare PCS with propofol/remifentanil to anesthesiologist-managed propofol sedation. DESIGN Prospective, randomized, controlled human trial. SETTING University hospital. PATIENTS This study involved 80 patients presenting for elective ERCP. INTERVENTION Patients were randomized to PCS with propofol/remifentanil (PCS group) or anesthesiologist-managed propofol sedation (propofol infusion group). Sedation level was estimated every 5 minutes throughout the procedure by using Ramsay and Gillham sedation scores. The total amount of propofol was calculated at the end of the procedure. Endoscopist and patient satisfaction with the procedures was evaluated with a structured questionnaire. MAIN OUTCOME MEASUREMENTS Patient vital signs, amount of consumed propofol, sedation levels, and degree of endoscopist and patient satisfaction. RESULTS PCS was successful with 38 of 40 (95%) ERCP patients. In the PCS group, the mean (±standard deviation) level of sedation was markedly lighter and propofol consumption significantly smaller (175±98 mg) than in the propofol infusion group (249±138 mg) (P<.01). Degrees of patient and endoscopist satisfaction were equally high in both groups. All of the patients preferred the same sedation method should a repeat ERCP be required. LIMITATIONS Single-center study. CONCLUSION PCS with propofol/remifentanil is a suitable and well-accepted sedation method for ERCP. Anesthesiologist-managed propofol sedation with constant propofol infusion is associated with unnecessary deep sedation without any impact on the degree of patient or endoscopist satisfaction. Further larger-scale studies are needed to assess the safety of PCS in ERCP patients. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01079312.).

Randomized multicenter study of multiple plastic stents vs. covered self-expandable metallic stent in the treatment of biliary stricture in chronic pancreatitis

BACKGROUND AND STUDY AIMS The use of covered self-expandable metallic stents (cSEMS) in benign biliary indications is evolving. The aim of the study was to assess the safety and feasibility of cSEMS compared with multiple plastic stents in the treatment of benign biliary stricture (BBS) caused by chronic pancreatitis. PATIENTS AND METHODS This was a prospective, multicenter, randomized study of 60 patients with BBS caused by chronic pancreatitis. All patients received an initial plastic stent before randomization. At randomization, the stent was replaced either with a single cSEMS or three plastic stents. After 3 months, the position of the cSEMS was checked or another three plastic stents were added. At 6 months after randomization, all stents were removed. Clinical follow-up including abdominal ultrasound and laboratory tests were performed at 6 months and 2 years after stent removal. RESULTS Two patients dropped out of the cSEMS group before stent removal. In April 2014, the median follow-up was 40 months (range 1 - 66 months). The 2-year, stricture-free success rate was 90 % (95 % confidence interval [CI] 72 % - 97 %) in the plastic stent group and 92 % (95 %CI 70 % - 98 %) in the cSEMS group (P = 0.405). There was one late recurrence in the plastic stent group 50 months after stent removal. Stent migration occurred three times (10 %) in the plastic stent group and twice in the cSEMS group (7 %; P = 1.000). CONCLUSION A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747).

Upregulated but insufficient generation of activated protein C is associated with development of multiorgan failure in severe acute pancreatitis

IntroductionDisturbed protein C (PC) pathway homeostasis might contribute to the development of multiple organ failure (MOF) in acute pancreatitis (AP). We therefore evaluated circulating levels of PC and activated protein C (APC), evaluated monocyte deactivation in AP patients, and determined the relationship of these parameters to MOF.Patients and methodsThirty-one patients in the intensive care unit were categorized as cases (n = 13, severe AP with MOF) or controls (n = 18, severe AP without MOF). Blood samples were drawn every second day to determine the platelet count, the levels of APC, PC, and D-dimer, and the monocyte HLA-DR expression using flow cytometry. The APC/PC ratio was used to evaluate turnover of PC to APC.ResultsDuring the initial two weeks of hospitalization, low PC levels (<70% of the adult mean) occurred in 92% of cases and 44% of controls (P = 0.008). The minimum APC level was lower in cases than in controls (median 85% versus 97%, P = 0.009). Using 87% as the cut-off value, 8/13 (62%) cases and 3/18 (17%) controls showed reduced APC levels (P = 0.021). A total of 92% of cases and 50% of controls had APC/PC ratios exceeding the upper normal limit (P = 0.013). Plasma samples drawn before MOF showed low PC levels and high APC/PC ratios. HLA-DR-positive monocytes correlated with PC levels (r = 0.38, P < 0.001) and APC levels (r = 0.27, P < 0.001), indicating that the PC pathway was associated with systemic inflammation-triggered immune suppression.ConclusionPC deficiency and decreased APC generation in severe AP probably contributed to a compromised anticoagulant and anti-inflammatory defence. The PC pathway defects were associated with the development of MOF. The data support feasibility of testing the use of APC or PC to improve the clinical outcome in AP.

Patient-controlled sedation for ERCP: a randomized double-blind comparison of alfentanil and remifentanil.

BACKGROUND AND STUDY AIMS Self-administration of a propofol and opioid mixture by patients (patient-controlled sedation, PCS) could offer a practical alternative for individual sedation during endoscopic retrograde cholangiopancreatography (ERCP). However, what would be the most suitable sedative mixture for PCS is unknown. The aim of this study was to compare remifentanil and alfentanil in the PCS during ERCP. PATIENTS AND METHODS Eighty-one patients undergoing elective ERCP received PCS with propofol and opioid in three different regimens. The concentrations of opioids in the sedative mixture were 0.02 mg/mL in the remifentanil group (R) and 0.04 mg/mL and 0.08 mg/mL in the alfentanil 1 (A1) and alfentanil 2 (A2) groups, respectively. The infusion pump was adjusted to deliver a 1 mL single dose with zero lockout time. We considered PCS as successful if no procedure interruption due to sedation-related complications occurred or if additional propofol was not needed. The consumption of propofol was registered, and sedation levels and vital signs were monitored. Endoscopist and patient satisfaction with sedation were assessed using structured questionnaires. RESULTS The consumption (SD) of propofol was 177 (105)mg in group R, 197 (88) mg in group A1 and 162 (70)mg in group A2. PCS was successful in 74 /81 (91 %) of sedations, without differences between the groups in terms of propofol consumption, sedation success rate, sedation levels, vital signs, postprocedural pain, and endoscopist and patient satisfaction. Respiratory depression and nausea were observed more frequently with remifentanil than with alfentanil (P < 0.05). CONCLUSIONS PCS is an acceptable method of sedation for ERCP. The combination of propofol and alfentanil should be recommended because a remifentanil - propofol mixture depresses spontaneous respiration more and produces nausea more frequently.

A randomized comparison of target-controlled propofol infusion and patient-controlled sedation during ERCP

BACKGROUND AND STUDY AIMS Propofol is widely used during endoscopic retrograde cholangiopancreatography (ERCP) but high doses are recognized as a risk factor for sedation-related complications. The aim of this study was to compare target-controlled infusion (TCI) with patient self-administration (patient-controlled sedation, PCS) of propofol during ERCP. Propofol consumption, the ease of ERCP performance, and speed of recovery were recorded. PATIENTS AND METHODS A total of 82 patients undergoing elective ERCP were randomized 1:1 to receive propofol 10 mg/mL using TCI (initial targeted effect-site concentration 2 μg/mL) or PCS (single bolus 1 mL, lockout time set at zero). Alfentanil was administered if signs of insufficient analgesia occurred. Consumption of propofol and alfentanil was recorded, sedation levels and vital signs were monitored, the ease of ERCP performance, speed of recovery, and satisfaction with sedation were evaluated. RESULTS All procedures were performed without interruptions or major sedation-related complications. The mean (± SD) consumption of propofol was 306 ± 124 mg in the TCI group and 224 ± 101 mg in the PCS group (P = 0.002). Patients in the PCS group recovered faster (P = 0.035). The mean (± SD) consumption of alfentanil was 0.5 ± 0.4 mg in both groups. The combination of propofol and alfentanil was associated with an increased risk of sedation-related adverse events (P = 0.031). CONCLUSIONS No benefits of TCI over PCS could be demonstrated in this study. We recommend considering PCS as a feasible option for propofol administration during ERCP because of its ease of use, high success rate, reduced consumption of propofol, and faster recovery.

Endoscopic treatment of anastomotic biliary complications after liver transplantation using removable, covered, self-expandable metallic stents

Abstract Objective. Anastomotic bile duct complications after liver transplantation (LT) have been treated endoscopically by dilation and plastic tube stenting, with the stent therapy having moved toward using covered, self-expandable metallic stents (cSEMS) in recent years. The aim of this study was to analyze therapy outcome of post-LT anastomotic complications using cSEMS. Material and methods. Seventeen post-LT patients had 29 cSEMS (Allium stent, n = 23; Wallstent®, n = 4; Micro-Tech, n = 2) placed during endoscopic retrograde cholangiopancreatography (ERCP). The fully covered stents (Allium, Micro-Tech) were placed entirely inside the common bile duct. Data were collected and analyzed in a retrospective manner. Results. These 17 patients had 19 stent treatment periods. Resolution was eventually established in all patients. There were four (14%) stent migrations. Pancreatitis was seen after one ERCP procedure, whereas five cases of cholangitis were seen. Conclusion. Treatment of post-LT anastomotic complications with cSEMS seems to be both safe and efficient. Further assessment regarding indications, stent types and stenting time is needed.

Circulating levels of a soluble form of receptor for advanced glycation end products and high-mobility group box chromosomal protein 1 in patients with acute pancreatitis.

Objectives: To study in patients with acute pancreatitis (AP) the plasma soluble form of the receptor for advanced glycation end products (sRAGE) and high-mobility group box chromosomal protein 1 (HMGB1) levels, followed-up for 12 days after hospitalization, in relation to the occurrence of organ failure and mortality. Methods: Thirty-eight patients with severe AP and organ failure (grade 2). A control group (127 patients) consisted of 38 patients with severe AP without organ failure (grade 1) and 89 patients with mild AP (grade 0). Plasma samples for determination of HMGB1 and sRAGE levels were collected on admission and on days 1 and 2, days 3 and 4, and days 7 and 12 after admission. Results: The median of the highest sRAGE levels was higher in grade 2 patients (472 pg/mL; interquartile range [IQR], 259-912) than in grade 0 plus grade 1 patients (349 pg/mL; IQR, 209-544; P = 0.024). Among the patients with detectable HMGB1, the median of the highest HMGB1 levels was 117 ng/mL (IQR, 56-212; n = 24) in grade 2 patients and 87 ng/mL (IQR, 54-161; n = 62) in grade 0 plus grade 1 patients (P = 0.310). Conclusions: We demonstrate that sRAGE level, but not HMGB1 level, is significantly higher in AP patients who develop organ failure than in AP patients without organ failure who recover.

Assessment of indications for percutaneous endoscopic gastrostomy--development of a predictive model.

Abstract Objective. Percutaneous endoscopic gastrostomy (PEG) is used for long-term enteral nutrition in neurological patients with dysphagia (NEUR), in head and neck cancer patients prior to chemoradiation therapy (head and neck malignancy group [HNM]), or in cases of oropharyngeal or esophageal tumor obstruction or stricture (OBSTR). Considerable morbidity and overall mortality is reported. Aim was to analyze the complication rates and mortality with PEG and to identify subgroups with poor outcomes. Material and methods. Patients underwent PEG (n = 401) in a single tertiary care center. Indications, characteristics, and causes of death were recorded. Results. Number of patients in groups: HNM 135 (34%), OBSTR 74 (18%), and NEUR 192 (48%); follow-up time median (interquartile range): 17 (39) months; the time PEG used for feeding: 4 (7) months. A total of 91 patients (23%) had 110 complications, 31 patients (8%) had early (≤30 days) complications, and 49 patients (12%) major complications. Two deaths (0.5%, 2 peritonitis) were related to PEG. The 30-day mortality was 11% (n = 47). According to multivariate analysis, an increased 30-day mortality was associated with ≥75 years of age, American Society of Anesthesiologists (ASA) class IV, a Charlson comorbidity index (CCI) ≥4, body mass index (BMI) <18.5, and ongoing antibiotic therapy. With this model, 95% specificity was obtained in the 30-day survival figures. Conclusion. The presented predictive model derived from our analysis may recognize patients with poor outcome when referred for PEG. The parameters in the present model (age, ASA class, CCI score, BMI, and data of ongoing antibiotic treatment) are easily measurable, and it is possible to integrate them into everyday work.