Roberto Blanco

Early versus late necrosectomy in severe necrotizing pancreatitis

BACKGROUND Debate as to whether surgery in severe necrotizing pancreatitis (SNP) should be done early or late has been present ever since the disease was described. There are no prospective, randomized studies addressing this specific issue. METHODS Patients with SNP, documented clinically, with Ransons criteria, and dynamic pancreatography (DP) findings were randomly allocated in two groups for treatment. Group A included early necrosectomy (within 48 to 72 hours of onset) and group B, late necrosectomy (at least 12 days after onset). Both groups continued with open packing and staged necrosectomies. Cultures were obtained at each laparotomy and necrosis was verified histologically in all instances. RESULTS During a 36-month study period, 150 patients with unequivocal acute pancreatitis were admitted for treatment. Forty-one with SNP initially entered the study; there were 5 drop outs. Patients in group A (25) and group B (11) had no difference in distribution by gender or mean age, etiology, mean Ransons signs (4 versus 3.8), DP findings, rate of infected necrosis, or necrosectomies required per patient. Although the mortality rate (58% versus 27%) did not reach statistical significance, the odds ratio for mortality was 3.4 times higher in group A, which made us finish the study. CONCLUSION This prospective, randomized study from a single institution clearly demonstrates that early intensive conservative treatment with late necrosectomy for selected cases is the current rationale approach for SNP.

Consideraciones quirúrgicas del bocio amiloide

Amyloidosis is an uncommon syndrome consisting of a number of disorders having in common an extracellular deposit of fibrillary proteins. This results in functional and structural changes in the affected organs, depending on deposit location and severity. Amyloid infiltration of the thyroid gland may occur in 50% and up to 80% of patients with primary and secondary amyloidosis respectively. Amyloid goiter (AG) is a true rarity, usually found associated to secondary amyloidosis. AG may require surgical excision, usually because of compressive symptoms. We report the case of a patient with a big AG occurring in the course of a secondary amyloidosis associated to polyarticular onset juvenile idiopathic arthritis who underwent total thyroidectomy. Current literature is reviewed, an attempt is made to provide action guidelines, and some surgical considerations on this rare condition are given.