A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis.

BACKGROUND: The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial. METHODS: Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo). RESULTS: Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays. CONCLUSION: The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

Results of the management of upper gastrointestinal bleeding from gastroesophageal varices.

INTRODUCTION: The management of upper gastrointestinal bleeding caused by rupture of gastric and/or esophageal varices in patients with liver cirrhosis must focus on the initial control of the haemorrhage avoiding further worsening of an already poor liver function and the prevention of early relapsing bleeding. Therapeutic options include endoscopic, pharmacological and surgical methods. MATERIAL AND METHODS: Prospective study of the results obtained after the follow-up of 90 bleeding episodes in a total of 54 patients, 35 men and 19 women, with a mean age of 58 years (range 32-77), to which a therapeutic protocol for acute bleeding secondary to portal hypertension was applied over a 22-months period. Patient classification according to Child-Pugh upon admission was 57% Child A, 34% Child B and 9% Child C. RESULTS: Mean hospital length of stay was 9 days (2-50). Of the 90 bleeding episodes, 15 were early relapsing bleeding episodes (16.7%). Twelve patients died (mortality rate of 22.2% by patients and 13.4% by bleeding episodes). Twelve emergency surgical procedures were performed because of the persistence of haemorrhage. Forty one per cent of patients were readmitted because of relapsing bleeding at least once during the follow-up period. CONCLUSIONS: Management of upper gastrointestinal bleeding due to gastroesophageal varices in patients with liver cirrhosis requires a combined therapy in order to attain maximum effectiveness in acute haemorrhagic episodes and to address all potential later consequences. Such therapy should be provided in a hospital fully equipped and with specialists in this pathology. Based on our experience, emergency surgery as rescue treatment for persistent or short-term relapsing bleeding should be restricted to patients with good hepatic function because of its high morbidity and mortality.

Cirugía radical del carcinoma de vesícula biliar / Radical surgery for gallbladder carcinoma

Introducción. El objetivo de este trabajo es analizar los resultados del tratamiento quirúrgico radical del carcinoma de vesícula biliar. Pacientes y métodos. Desde 1996 a 1999 han sido intervenidos con intención curativa 12 pacientes afectados de carcinoma de vesícula biliar. En 10 casos se trataba de un hallazgo incidental después de una colecistectomía simple. La intervención quirúrgica propuesta fue linfadenectomía del hilio hepático con segmentectomía IVb y V. La resección de la vía biliar se incluyó en función de los hallazgos intraoperatorios. Resultados. La estadificación pTNM definitiva fue: estadio I en 2 casos, estadio II en 2 casos, estadio III en 5 casos y estadio IV en 3 casos. No hubo mortalidad postoperatoria. En 5 pacientes no se produjo ninguna complicación. La estan cia mediana fue de 10,5 días. La supervivencia actuarial a los 32 meses es del 61 por ciento. La supervivencia según el grado de invasión ganglionar fue significativa (p = 0,005), estando vivos todos los pacientes pN0. Conclusiones. En los tumores incidentales la reintervención es obligatoria en los tumores pT2-3 y pN1. No obstante, si no se puede garantizar un margen de resección de vesícula no invadido, o bien el tumor se extiende hasta la capa muscular (pT1b), es mejor reintervenir a estos enfermos. La actitud terapéutica en los pT4 y pN2 debe ser paliativa. La reintervención de estos pacientes debería llevarse a cabo en centros con especial dedicación a cirugía hepatobiliopancreática para disminuir la morbimortalidad (AU)

Resultados en el tratamiento de la pancreatitis aguda grave / Results of treatment in severe acute pancreatitis

OBJETIVO: analizar los resultados obtenidos en el tratamiento médico y quirúrgico de la pancreatitis aguda grave (PAG). PACIENTES Y MÉTODOS: se estudiaron, retrospectivamente, 90 pacientes ingresados desde enero de 1992 hasta enero de 1998, con PAG según criterios clínicos y radiológicos. Se realizó una tomografía computarizada con contraste e.v. (TC) en todos. La técnica quirúrgica de elección fue la necrosectomía y lavados continuos del lecho pancreático. RESULTADOS: el 70 por ciento (63/90) de los pacientes presentaron necrosis pancreática. La tomografía computarizada (TC) tuvo una sensibilidad del 73 por ciento para diagnosticar necrosis. Se operaron el 54 por ciento de los pacientes (49/90): 31 presentaban PAG infectada y 18 estéril. La mortalidad global fue del 25,6 por ciento (23/90), siendo del 43,8 por ciento (14/32) en la infectada y del 15,5 por ciento (9/58) en la estéril (p < 0,05). Esta aumentó a un 44,4 por ciento (8/18) en la estéril que precisó tratamiento quirúrgico. La mortalidad fue mayor en la PAG infectada operada en la primera semana del ingreso (81 por ciento) respecto a la que se intervino posteriormente (20 por ciento) (p < 0,05). CONCLUSIONES: la necrosis pancreática y la infección de la misma son los factores pronósticos más importantes en la evolución de la PAG. La mortalidad es significativamente mayor en los pacientes con necrosis infectada que fueron intervenidos durante la primera semana. Nuestros esfuerzos deben ir dirigidos no sólo a evitar la infección de la necrosis y el fracaso orgánico, sino a retrasar en lo posible el momento de la intervención quirúrgica si ésta es necesaria (AU)

Results of treatment in severe acute pancreatitis.

AIM: To analyze our results in the management of severe acute pancreatitis (SAP), especially in patients who required surgery. METHODS: In a retrospective study, 90 patients admitted between January 1992 and January 1998 were diagnosed as having SAP on the basis of clinical and radiological criteria. Contrast-enhanced tomography (CT) was done in all patients. The surgical technique of choice was necrosectomy and postoperative local lavage. RESULTS: Seventy percent of the patients (63/90) had pancreatic necrosis. Tomography had a sensitivity of 73% in detecting necrosis. Forty-nine patients (54%) needed surgery: 31 had infected SAP and 18 had sterile pancreatitis. Overall mortality rate was 25.6% (23/90); mortality was 43.8% (14/32) in patients with infected pancreatitis and 15.5% (9/58) in those with sterile SAP (p < 0.05). The mortality rate was 44.4% higher (8/18) in patients with sterile SAP who were operated on. Patients with infected SAP who were operated on during the first week of admission had a higher mortality rate (81%) than those operated on after the first week (20%) (p < 0.05). CONCLUSIONS: Pancreatic necrosis and infection are the most important prognostic factors in the course of SAP. The sooner the patients are operated on, the worse the prognosis, especially if there is infection. Efforts should be aimed at avoiding the onset of infection and organ failure, and at delaying surgery.

Vascular occlusion in hepatic resections in cirrhotic rat livers: an experimental study in rats.

The aim of this study was to evaluate the tolerance of normothermic liver ischemia with different degrees of hepatic function in cirrhotic rats. Liver cirrhosis was induced by administering carbon tetrachloride (CCl4) in water solution to male Wistar rats. Hepatic function was graded using the plasma levels of antithrombin III, albumin, and bilirubin and the presence of ascites. Rats were distributed in four groups: noncirrhotic (control group), compensated cirrhosis (group A), decompensated cirrhosis (group B), and decompensated cirrhosis with ascites (group C). Groups A, B, and C were significantly different in all four parameters studied (P < .003). Subtotal liver ischemia was performed for periods of 0, 30, 45, 60, and 75 minutes. At the end of the procedure, the nonischemic lobes were resected. Postoperative evolution of alanine aminotransferase, aspartate aminotransferase, and bilirubin levels was also recorded. Survival rates after the same periods of ischemia were statistically different (P < .05): control group, 7 of 7 after 45 minutes (100%), 7 of 7 after 60 minutes (100%), and 4 of 9 after 75 minutes (44%); group A, 7 of 7 after 45 minutes (100%) and 1 of 7 after 60 minutes (14%); group B, 7 of 7 after 0 minutes (100%), 5 of 7 after 30 minutes (71%), and 1 of 7 after 45 minutes (14%); and group C, 0 of 5 after 0 minutes (0%) and 1 of 7 after 30 minutes (14%). No differences were found in the postoperative course of transaminases. However, bilirubin levels found 24 hours and 7 days after ischemia were significantly greater in cirrhotic rats, and this was directly related to the degree of hepatic insufficiency (P < .001). Histological examination of the livers exposed to CCl4 showed features of liver cirrhosis with ductal proliferation. The ischemia time tolerated by cirrhotic rat livers is shorter than the time tolerated by normal rats. Tolerance to hilar vascular occlusion depends on the degree of hepatic insufficiency. Rats with decompensated cirrhosis and ascites do not tolerate any surgical procedure.

[Surgical treatment of emergency pathology of the left colon]. / Tratamiento quirúrgico de la patología urgente del colon izquierdo.

The aim of this study was to evaluate the postoperative morbidity and mortality of patients with left colon disease that underwent emergency surgery. Intra-operative colonic irrigation (ICI) with primary anastomosis was used for unresectable lesions, faecal peritonitis, colon remnant associated lesions and poor performance status. The options included colostomy, Hartmann procedure or subtotal colectomy; 127 resections of left-sided large bowel were performed. In 56 cases the procedure was a Hartmann operation, in 38 cases subtotal colectomy and in 33 ICI. The most frequent complication was abdominal sepsis (29%). The overall mortality was 24%; 39% for the Hartmann procedure; 16% for subtotal colectomy and 6% for ICI. Our results suggest that ICI should be the first choice in patients with good performance status who undergo emergency surgery for left colon disease without faecal peritonitis or associated right colon lesions.

[Left hemicolectomy and intraoperative antegrade lavage in emergency surgery of the left colon]. / Hemicolectomía izquierda y lavado anterógrado peroperatorio en el tratamiento de la patología urgente del colon izquierdo.

We report our results with a left colonic resection and intraoperative antegrade colonic irrigation technique with primary anastomosis. Thirty five consecutive patients operated on in the Emergency Surgical Ward are presented. Twenty five with large bowel occlusion and 10 with sigma perforation. Anastomotic leakage (2 patients, 5.7%) and postoperative hospital stay (mean 15 days) were similar to cases of elective surgery. The intraoperative antegrade colonic irrigation technique has become the first choice in our Department to treat any patient with left colonic occlusion or perforation. Only patients with faecal peritonitis or ischemic colon were excluded.