minimally invasive management for abdominal compartment syndrome in severe acute pancreatitis

Three patients with severe acute pancreatitis [SAP] developed into overt abdominal compartment syndrome [ACS] and confirmed or suspected infection of necrotic tissue. We successfully treated these patients by minimally invasive decompression with the assist of laparoscope after the failures of intensive care treatments. This technique we report here may be another safe and effective management for ACS in SAP

Standard versus extended pancreaticoduodenectomy in treating adenocarcinoma of the head of the pancreas / 中国医学科学杂志(英文版)

<p><b>OBJECTIVES</b>To compare the postoperative complications and survival of standard pancreatoduodenectomy (SPD) and extended pancreatoduodenectomy (EPD) in patients with resectable adenocarcinoma of the head of the pancreas.</p><p><b>METHODS</b>Between January 1994 and December 2011, 165 patients with biopsy-proven adenocarcinoma of the pancreatic head were treated in West China Hospital, among whom 93 underwent SPD and 72 had EPD. Complications and survival after the surgery were analyzed retrospectively.</p><p><b>RESULTS</b>The median operation time of the EPD group was longer compared with the SPD group (375 minutes vs.310 minutes, P<0.01), the volume of blood transfusion was larger (700 mL vs.400 mL, P<0.05), while the median hospital stay (13.5 days vs.12 days, P=0.79) and the total complication rates were comparable (34.7% vs.32.4%, P=0.93). The total recurrence rates of the SPD and EPD groups were not significantly different (52.7% vs. 43.1%, P=0.83). No significant differences were found between the SPD and EPD groups in 1-year (81.7% vs. 86.1%), 3-year (38.7% vs. 43.1%), 5-year (16.7% vs. 19.4%), and median survivals (19.8 months vs. 23.2 months, P= 0.52).</p><p><b>CONCLUSION</b>The postoperative complications and survival donot differ significantly between SPD and EPD.</p>

Transcatheter arterial embolization for postoperative intraperitoneal and gastrointestinal hemorrhage in a patient with severe acute pancreatitis

Pancreatitis is associated with pseudoaneurysm in 4-10% of patients. Intraperitoneal and gastrointestinal hemorrhage resulting from rupture of a pseudoaneurysm is an uncommon complication of pancreatitis. We report a male with severe acute pancreatitis presenting with intraperitoneal and gastrointestinal hemorrhage 13 days and 68 days after debridement and drainage of infected necrosis of pancreas, which were successfully managed by a transcatheter arterial embolization with "two points" [both sides of the bleeding point]. This case not only reveals the management of intraperitoneal and gastrointestinal hemorrhage, but also indicates "two points" embolization could be the definitive therapy for hemorrhage secondary to severe acute pancreatitis

Grade IV blunt pancreatic trauma and pseudocyst successfully treated with Ultrasound-guided percutaneous catheter drainage

We present a 16-year-old boy with complete major pancreatic duct disruption in pancreatic neck. According to the American Association of Surgical Trauma Classification, the patient was diagnosed with pancreatic injuries grade IV and pseudocyst which was managed successfully by way of Ultrasound-guided percutaneous catheter drainage

Management of postoperative acute intraperitoneal and gastrointestinal hemorrhage in patients with severe acute pancreatitis

Acute intraperitoneal and gastrointestinal hemorrhage [AIGH] is a fatal postoperative complication of severe acute pancreatitis [SAP]. Prompt diagnosis and correct treatment of AIGH remain a challenge. The current study presents the procedures undertaken by a single institution in managing postoperative AIGH in patients with SAP. Thirty-four patients with SAP who exhibited AIGH after debridement and drainage of infected necrosis were analyzed retrospectively. Clinical presentations, vessels and accompaniments involved in bleeding, and the diagnostic methods, as well as the therapeutic approaches and outcomes were reviewed. All patients exhibited AIGH 47 times. Fresh blood flowing out from abdominal drains and bloody stools were the predominant [44.9%] symptoms for AIGH. Ten patients that bled several times underwent early surgeries, and 5 of them repeatedly underwent surgeries. Splenic artery was the vessel most commonly involved in bleeding [46.8%]. Seventeen patients bled in one site 23 times, accompanied by gastrointestinal or choledochal fistula. Seventeen patients bled in multiple sites 24 times. AIGH cases were diagnosed successfully by contrast-enhanced computed tomography [51.7%] and arteriography [46.8%]. Transcatheter arterial embolization [TAE] with "one point" was performed 7 times with 5 [71.4%] recurrent bleedings, whereas TAE with "two points" was performed 12 with only 1 [8.3%] re-bleeding. Early surgical intervention and repeated surgery are two risk factors of AIGH. This condition is related to either one-site bleeding accompanied by a gastrointestinal or choledochal fistula or multi-site bleeding. The diagnostic methods and treatments should be selected based on venous or arterial bleeding. A disciplined three-vessel mesenteric arteriogram should be obtained, and TAE with "two points" embolization is recommended to stop arterial bleeding

The POSSUM scoring system for risks assessment in pancreatoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the value of the POSSUM scoring system in predicting postoperative morbidity and mortality of pancreatoduodenectomy (PD).</p><p><b>METHODS</b>Two hundreds and sixty-five consecutive PDs were performed between January 2005 and December 2007. POSSUM scores which relied on 12 physiologic and 6 operative variables were prospectively calculated for each case. Expected morbidity and mortality were estimated based on POSSUM scores and were compared with observed morbidity, which were diagnosed according to the Clavien complication scheme and domestic reference criteria respectively, and mortality.</p><p><b>RESULTS</b>Physiologic scores of 265 cases ranged from 12 to 24,the mean was 15. Operative scores ranged from 14 to 24, the mean was 17. The overall POSSUM scores ranged from 0.24 to 0.88. Average expected morbidity was 43.8%, expected cases were 116. Observed morbidity rate was 39.6% (105/265). The expected and observed morbidities and cases had no significantly differences. All patients were classified to 1 of 4 strata based on their individual POSSUM scores and subsequent risk of morbidity. Predictive value was the highest when scores ranged from 0.4 to 0.8. POSSUM exhibited less predictive value for mortality, but if POSSUM was more than 0.5, it was useful for mortality predicting.</p><p><b>CONCLUSIONS</b>POSSUM scoring system has high value for predicting the risk of morbidity in PD and can be helpful in guiding surgery and postoperative management decisions.</p>

Effects of early goal-directed fluid therapy on intra-abdominal hypertension and multiple organ dysfunction in patients with severe acute pancreatitis / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the effects of early goal-directed fluid therapy with hydroxyethyl starch 130/0.4 on intra-abdominal hypertension (IAH), multiple organ dysfunction and fluid balance in severe acute pancreatitis (SAP) patients.</p><p><b>METHODS</b>According to the criteria of selection and exclusion, 120 SAP patients within 72 hours after the symptom occurred from 4 study sites were recruited. They were given standard medication according to "the guideline of diagnosis and treatment of SAP in China" in SICU or PICU. The patients were randomly divided into two groups with crystalloid (control group) and colloid plus crystalloid resuscitation (research group). The objective of fluid therapy was to keep steady hemodynamics for 8 days. IAP was measured three times daily by means of urinary bladder transduction. Function of liver, renal and lung were detected daily. APACHE II score and fluid balance were calculated daily.</p><p><b>RESULTS</b>Total 120 cases were recruited into research group (n = 59) and control group (n = 61). The demography and baseline data were comparable. IAP was lower in research group than that in control group at day 4 and day 5 (P < 0.05). There was no significant difference in APACHE II scores between two groups pre- and after admission. The decline of daily IAP to baseline (DeltaIAP) in research group was significantly higher than in research group from day 2 to day 8(P < 0.05), whilst the decline of daily APACHE II score to baseline (DeltaAPACHE II score) in research group were significantly higher from day 4 to day 8 (P < 0.05). Negative fluid balance emerged much earlier in the research group (P = 0.036). Percentage of patients with negative fluid balance within 8 days was significantly higher in research group than that in control group (94.9% vs. 62.3%). The amount of positive fluid balance was significantly lower in research group (P = 0.039). IAP correlated significantly with APACHE II score (r(2) = 0.322, P = 0.000). PaO2/FiO2 was significantly higer in research group at day 4 and day 8.</p><p><b>CONCLUSIONS</b>It is very important to pay close attention to IAP in early fluid therapy of SAP patients. Early goal-directed fluid therapy with HES130/0.4 shortens the duration of positive fluid balance, decreases the amount of positive fluid balance, reduces APACHE II score, relieves IAH, and improves PaO2/FiO2.</p>

Effect of curved cutter stapler in the ultra low anterior resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the curative effect of curved cutter stapler (Contour, Ethicon Endo-Surgery, Inc) in the ultra low anterior resection for low rectal cancer.</p><p><b>METHODS</b>Clinic data of 56 patients with low rectal cancer from Dec. 2005 to Sep. 2006 were reviewed retrospectively. After total mesorectal excision (TME) and lateral lymph node dissection (LLD) in 56 cases, the rectal (anal) remnant was cut and closed with curved cutter stapler (Contour), and preserved for ultra low colo-rectal (anal) anastomoses with 33 mm straight intraluminal stapler.</p><p><b>RESULTS</b>There was no operational death and the mean hospitalization time was (11.2+/-3.2) days. The incidence rate of postoperative complications in 1 month was 3.57% (2/65). Both of the cases were anastomotic leakage. One was cured by surgical drainage, the other combining with rectal vaginal fistula was cured by transverse colostomy.</p><p><b>CONCLUSION</b>Curved cutter stapler has the advantages of complete cutting, safe closure and low anastomotic leakage rate in the process of ultra low anterior resection for low rectal cancer.</p>

Diagnosis and surgical treatment of abdominal cocoon: a report of 16 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the diagnosis and surgical treatment of abdominal cocoon.</p><p><b>METHODS</b>The clinical data of 16 patients with abdominal cocoon admitted to our hospital between Jun. 1993 and Oct. 2006 were analyzed retrospectively.</p><p><b>RESULTS</b>Preoperatively, Barium meal X-rays revealed coils of intestine in 8 cases, incomplete intestinal obstruction in 6 cases, and prolonged intestinal transit time in 2 cases. CT scan showed dilated intestine and intestinal loops seemed to be encapsulated in a thickened capsule. After opening the peritoneum, entire or partial intestine encapsulated in thickened membrane encasing were found, including partial intestine encapsulated in 1 cases(Type I), entire intestine encapsulated in 2 cases (Type II), and entire intestine and other organs encapsulated in 12 cases(Type III). All the cases underwent adhesiolysis. Intestinal splint was done in 2 patients, gastrostomy in one patient with chronic pyloric obstruction, radical resection of rectal cancer in one patients and ileocolic resection in one patients with Crohn's disease. All patients were healed by surgical operation and confirmed the diagnosis histopathologically.</p><p><b>CONCLUSIONS</b>Abdominal cocoon is rare. It is difficult to make a right diagnosis preoperatively. Barium meal X-rays and CT scan are useful methods for its diagnosis. For the treatment, attention should be paid on complete resection of fibrous membrane, adhesiolysis and prevent intestinal obstruction.</p>

Establishment of whole pancreaticoduodenal allotransplantation model with portal venous drainage and enteric drainage in pigs / 南方医科大学学报

<p><b>OBJECTIVE</b>To establish an porcine model of whole pancreaticoduodenal transplantation with portal venous drainage and enteric drainage for ensuring physiologically normal function without hyperinsulinemia and reducing postoperative complications.</p><p><b>METHODS</b>Twenty sichuan native outbreding white pigs weighing 25-30 kg were divided equally into two groups to serve as the donors and recipients. Cooling of the grafts was accomplished with in situ flush with 4 degrees C UW preservation solution via an aortic cannula. A whole pancreatoduodenal graft with the segment of abdominal aorta and the portal vein was harvested from the donor pigs. Type I diabetes model was established by complete removal of the recipient pancreas. The whole pancreatoduodenal graft was preserved and shaped in UW solution, and the subphrenic abdominal aorta of the recipient was joined with the donor abdominal aorta via a side-to-end anastomosis, and venous reflux was reconstructed between the donor portal vein and the recipient superior mesenteric vein. Side-to-side intestinal anastomosis was performed between the donor duodenum and the recipient jejunum.</p><p><b>RESULTS</b>Ten pancreaticoduodenal transplantations (PVE+ED style) were done, and pancreatic graft thrombosis and embolism occurred only in 1 pig 6 days after transplantation.</p><p><b>CONCLUSION</b>The model of whole pancreaticoduodenal transplantation with portal venous drainage and enteric drainage is stable and reliable.</p>

Clinical comparison on the classical versus extensive Whipple's resection for adenocarcinoma of head of pancreas / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the effect of extensive Whipple's resection to the adenocarcinoma of head of pancreas on the survival, complications, and surgical mortality.</p><p><b>METHOD</b>Ninety three patients who received Whipple's surgery between January 1995 and March 2003 were divided into classical group (n = 51) and extensive group (n = 42). Their short-term outcome and survival rate were compared retrospectively.</p><p><b>RESULTS</b>The postoperative complication rate and mortality in classical group and extensive group were 19.61%/3.92% and 16.67%/2.38%, respectively. And 1- and 2- year survival rates in classical group and extensive group were 58.82%/20.59% and 63.33%/23.33%, respectively.</p><p><b>CONCLUSIONS</b>Postoperative complications and mortality will not increase in extensive Whipple's resection for adenocarcinoma of head of pancreas. However, whether extensive Whipple's resection will improve long-term survival still requires further investigation.</p>