Clinical relevance of intra-abdominal hypertension in patients with severe acute pancreatitis.

OBJECTIVES: Intra-abdominal hypertension (IAH) contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of abdominal compartment syndrome (ACS). This study aims to investigate the clinical significance of IAH in patients with severe acute pancreatitis (SAP). METHODS: Patients admitted to intensive care with SAP underwent daily measurement of intra-abdominal pressure (IAP), recording of the clinical data, and calculation of 4 organ dysfunction scores. RESULTS: Among 18 patients with SAP, 11 (61%) developed IAH (median, 20 mm Hg), whereas 10 (56%) developed ACS. The IAP correlated significantly with the 4 organ dysfunction scores; the scores were significantly higher when IAH existed than when it did not. The admission IAP correlated significantly with the duration of intensive care stay. Patients who developed IAH/ACS had significantly higher organ failure score and greater mortality compared with those who did not. Laparotomy and drainage reduced the IAP by a median of -11 mm Hg and relieved the IAH/ACS in all patients. CONCLUSIONS: Intra-abdominal hypertension and ACS are frequent findings in patients with SAP and are associated with deterioration in organ function. Intra-abdominal pressure correlates with the severity of organ failure, and a high admission IAP is associated with prolonged intensive care stay.

Mild ERCP-induced and non-ERCP-related acute pancreatitis: two distinct clinical entities?

BACKGROUND: The aim of this study was to evaluate the hypothesis that mild endoscopic retrograde cholangiopancreatography (ERCP)-induced acute pancreatitis (AP) runs a distinctly shorter clinical course compared with mild attacks caused by other etiological factors. METHODS: ERCP-induced AP was defined as the persistence of postprocedure abdominal pain requiring analgesia for at least 24 h in association with hyperamylasemia of more than three times the normal value. Among 2552 patients who had undergone ERCP between 1996 and 2002 in two different hospitals, mild AP developed after "elective" ERCP in 48 (group I). Among a random sample of 10% of 700 patients admitted with AP to both hospitals during the same study period, 58 had mild non-ERCP-related AP (group II). Results shown are medians. RESULTS: Patients in group I had significantly shorter durations of pain (55 vs. 114 h, P < 0.0001), analgesic intake (56 vs.93 h, P = 0.007), and intravenous hydration (48 vs. 80 h, P < 0.0001), a lower opiate analgesic requirement (58 mg morphine equivalent vs. 100 mg, P = 0.001), a shorter time to resumption of oral diet (3 vs. 5 days, P < 0.0001), and a shorter hospital stay (4 vs. 7 days, P < 0.0001) than patients in group II. CONCLUSIONS: The current definitions of ERCP-induced AP select a cohort of patients whose mild attacks run a significantly shorter and milder course than non-ERCP-related mild attacks. A new consensus definition of ERCP-induced AP that describes attacks of similar clinical course is needed.

Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery.

BACKGROUND/PURPOSE: Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce. METHODS: Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases. RESULTS: There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219). CONCLUSIONS: Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.

An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery.

Laparoscopic appendectomy, cholecystectomy, or anti-reflux procedures are conventionally performed with the use of one and often two 10/12-mm ports. While needlescopic or micropuncture laparoscopic procedures reduce postoperative pain, they invariably involve the use of one 10/12-mm port and the instruments applied have their ergo-dynamic shortcomings. Between September 2002 and March 2003, we have attempted an "all 5-mm ports" approach in 49 laparoscopic procedures, which included 18 of 59 laparoscopic cholecystectomies (31%), 26 diagnostic laparoscopies for suspected appendicitis (of which we proceeded to a laparoscopic appendectomy in 17 patients), and in the last 5 of 9 laparoscopic Nissen fundoplications. Conversion of one of the 5-mm ports to a 10-mm port was required in 5 of the 18 (28%) laparoscopic cholecystectomies and in 6 of the 17 (35%) laparoscopic appendectomies to facilitate organ retrieval in patients with large gallstones (>5 mm in diameter) and in obese patients with fatty mesoappendix. There were no conversions to open surgery. No significant differences in the operating time between the laparoscopic procedures performed by the all 5-mm ports approach or the conventional approach were observed. No intraoperative or postoperative complications occurred in this series. The "all 5-mm ports" approach to laparoscopic cholecystectomy and appendectomy in selected patients and to laparoscopic fundoplication appears feasible and safe. A randomised comparison between this approach and the conventional laparoscopic approach to elective cholecystectomy and fundoplication in which two of the ports employed are of the 10-mm diameter is warranted.