Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery.

BACKGROUND: Epidural analgesia is the mainstay of perioperative pain management in enhanced recovery programmes. This study compared short-term outcomes following epidural or intrathecal analgesia in patients undergoing elective laparoscopic colorectal surgery. METHODS: A single-centre observational study was carried out in 175 consecutive patients who had elective laparoscopic colorectal surgery for benign or malignant disease within an enhanced recovery programme. Seventy-six patients received epidural analgesia and 99 had a single injection of intrathecal analgesia to provide perioperative pain control. RESULTS: Patients who had intrathecal analgesia had a reduced median postoperative pain score compared with those receiving epidural analgesia (0 versus 3.5; P < 0.001), an earlier return to mobility (1 versus 4 days; P < 0.001) and a shorter hospital stay (4 versus 5 days; P < 0.001). Return to normal gut function and postoperative nausea and vomiting were similar in the two groups. CONCLUSION: Intrathecal analgesia may have advantages over epidural analgesia in patients undergoing laparoscopic colorectal surgery.

Hyperlipidaemia and outcome in acute pancreatitis.

There is a well-recognised association between hyperlipidaemia and acute pancreatitis. However, the role of hyperlipidaemia in modulating disease course is not clear. The aim of the study was to conduct a prospective study in acute pancreatitis to assess the relation between hyperlipidaemia and disease severity using current disease descriptors. The study population constituted 43 patients with acute pancreatitis, admitted during the calendar year 2001. There were 19 (44%) males. The median (range) age was 50 (21-86) years. Serum triglycerides, cholesterol and high-density lipids were measured on admission. Patients were followed-up for at least 6 months after discharge. Principal outcomes were relation between hyperlipidaemia and peri-pancreatic complications and end-of-episode disease severity. The results showed that hypertriglyceridaemia was present in 14 patients (33%). There was a significant difference in mean (SEM) serum triglyceride levels between patients with alcohol-induced pancreatitis compared with pancreatitis of other aetiologies [3.07 (1.0) mmol/l vs. 1.26 (0.11) mmol/l; p = 0.03, Fisher's exact test]. There was no correlation between admission hypertriglyceridaemia and admission APACHE II score (r(2) = 0.0015). Similarly, there was no correlation between triglyceride level and either pancreatic inflammatory complications or final outcome. In conclusion, this study has demonstrated that there was no significant correlation between hypertriglyceridaemia and either complications of disease or overall end-of-episode severity in this population of patients with acute pancreatitis.

Intravenous n-acetylcysteine, ascorbic acid and selenium-based anti-oxidant therapy in severe acute pancreatitis.

BACKGROUND: To observe outcome in a cohort of patients with severe acute pancreatitis receiving multiple anti-oxidant therapy. METHODS: An observational study was carried out in 46 consecutive patients with acute pancreatitis fulfilling current Atlanta consensus criteria for severe disease. All patients received multiple anti-oxidant therapy based on intravenous selenium, N-acetylcysteine and ascorbic acid plus beta-carotene and alpha-tocopherol delivered via nasogastric tube. Principal outcomes were the effect of anti-oxidant supplementation on anti-oxidant levels, morbidity and mortality in patients on anti-oxidant therapy, case-control analysis of observed survival compared to predicted survival derived from logistic organ dysfunction score (LODS), logistic regression analysis of factors influencing outcome and side effect profile of anti-oxidant therapy. RESULTS: Paired baseline and post-supplementation data were available for 25 patients and revealed that anti-oxidant supplementation restored vitamin C (P = 0.003) and selenium (P = 0.028) toward normal. In univariate survival analysis, patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 12.6% for each unit increase (95% CI 6.0% to 19.6%). The mean LODS calculated on admission to hospital was 3.7 (standard error of the mean 4.1) giving a predicted mortality for the cohort of 21%. The observed in-hospital mortality was 43%. CONCLUSIONS: Case-control analyses do not appear to demonstrate any benefit from the multiple anti-oxidant combination of selenium, N-acetylcysteine and ascorbic acid in severe acute pancreatitis.

Acinar cell carcinoma of the pancreas with and without endocrine differentiation.

BACKGROUND: Acinar cell carcinoma (ACC) is a rare pancreatic neoplasm, representing 1% of exocrine tumours and containing a variable endocrine component. Three recent cases of ACC are reported. CASE OUTLINES: A 72-year-old man with painless obstructive jaundice had a 5-cm mass in the head of pancreas resected by Whipple's operation; histopathological examination showed a typical ACC. A 33-year-old man with weight loss and abnormal liver function had a dilated biliary tree but no mass on imaging. Pylorus-preserving pancreatoduodenectomy was performed, and histology showed a mixed acinar-neuro-endocrine tumour. A 56-year-old man with weight loss and a palpable mass had a 15-cm mass in the distal body of pancreas, which was resected en bloc with the spleen and adherent stomach; it was a cystic ACC. RESULTS: Two patients are alive and free of disease at 30 months and 15 months, while the third patient with locally advanced disease died of myocardial infarction at 9 weeks. DISCUSSION: Acinar structures are the hallmark of this neoplasm, which carries a better survival rate than ductal cancer. Surgical excision prolongs survival and offers the best chance of cure.

Gastropleural fistula originating from the lesser curve: a recognised complication, an uncommon pathway of communication.

Fistulous communications between the abdominal and the pleural cavity are rare; they implicate intra-abdominal sepsis. We present a rare case of subphrenic abscess following gastric perforation, which resulted in thoracic empyema. This report emphasises that gastropleural fistulas, although uncommon, should be considered in differential diagnoses of thoracic empyema, especially when there is a longstanding history of peptic ulceration.

Parathyroid hormone-related peptide in pancreatic neuroendocrine tumours associated with hypercalcaemia.

BACKGROUND: Hypercalcaemia is a common paraneoplastic syndrome. In the context of pancreatic neuroendocrine tumours, it is occasionally caused by secretion of parathyroid hormone-related peptide (PTH-rP). CASE OUTLINES: Two patients are reported in whom persistent hypercalcaemia was traced to a large neuroendocrine pancreatic tumour hypersecreting PTH-rP. Resection of the tumour reduced serum levels of calcium and PTH-rP transiently in each case until the patient developed bulky metastatic disease. A 33-year-old woman remained hypercalcaemic after the removal of all four hyperplastic parathyroid glands had rendered circulating parathormone levels undetectable. Radical distal pancreatectomy was followed over the next 4 years by operative debulking of liver metastases, multiple hepatic artery embolisations, octreotide injections and repeated admissions for intravenous fluid and biphosphonate therapy. A 41-year-old man presented with hypercalcaemia as well as features of somatostatinoma syndrome. Symptomatic improvement after radical distal pancreatectomy was short-lived, and hepatic artery embolisation failed to control his rapidly progressive disease. DISCUSSION: Malignant hypercalcaemia associated with a neuroendocrine pancreatic tumour hypersecreting PTH-rP is difficult to treat and can be life-threatening. Aggressive surgical treatment is recommended initially, while somatostatin analogues and hepatic artery embolisation are alternative therapeutic options for metastatic disease.