Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis.

BACKGROUND: In patients with chronic pancreatitis, an actively bleeding pseudoaneurysm can be life-threatening. Angioembolization is an attractive alternative to often complex operative management, and its feasibility was assessed in a retrospective analysis. METHODS: During 1993-2005, 33 patients (27 males, median age 51 years) with bleeding pancreatic pseudoaneurysms underwent urgent angiographic evaluation followed by angioembolization if possible. Angioembolization was performed in 23 patients, whereas 10 patients required hemostatic surgery, including 6 distal pancreatectomies and 3 vessel ligations. RESULTS: Between 1993 and 2005 33 out of 745 patients (4.4%) admitted for chronic pancreatitis had bleeding pancreatic pseudoaneurysms. The proportion of bleeders out of the total number of hospital admissions for chronic pancreatitis was 33 out of 1,892 (1.7%). The overall success rate of angioembolization was 22 out of 33 (67%) including 3 patients requiring re-embolization for recurrent bleeding. The success rate was 16 out of 20 (80%) when the pseudocyst was in the head of the pancreas, and only 50% when the splenic artery was the source of bleeding. Four of the 5 cases with free bleeding into the peritoneal cavity required operative intervention. The overall mortality and morbidity rates were 2 out of 33 (6%) and 7 out of 33 (21%) respectively, with no significant differences between embolized and operated patients. Angioembolization was associated with a significantly lower need for total blood transfusions and length of hospital stay. During the years 2000-2005, the overall success rate of angioembolization was 95%. CONCLUSIONS: All hemodynamically stable patients with chronic pancreatitis and bleeding pseudoaneurysms should undergo prompt initial angiographic evaluation and embolization if possible. Repeated angioembolization is feasible in patients with recurrent bleeding, whether initially embolized or operated. Patients with unsuccessful embolization should undergo emergency hemostatic surgery with ligation of the bleeding vessel in the head of the pancreas and distal resection in patients bleeding from the splenic artery or its branch. The combination of angioembolization and later endoscopic drainage of the pseudocyst via endoscopic retrograde cholangiopancreatography (ERCP) is effective in the majority of the cases of pseudoaneurysms in chronic pancreatitis.

AMES, MACIS and TNM prognostic classifications in papillary thyroid carcinoma.

The need for total thyroidectomy and extended for lymphadenectomy and the need for postoperative radioiodine ablation in the treatment of papillary thyroid carcinoma is continuously debated. Since less aggressive treatment in low-risk patients has been suggested, several scoring systems have been developed to identify low-risk patients. In the current study, we compared the AMES, MACIS and TNM staging systems in predicting carcinoma-specific mortality in papillary thyroid carcinoma. Between 1967 and 1994, 495 patients with papillary thyroid carcinoma were treated at the Department of Surgery, Helsinki University Central Hospital. Carcinoma-specific mortality in the AMES low-risk group, comprising 89.7% of these patients, was 2.4%. Corresponding figures for the MACIS were 89.9%, and 2.4%, and for the TNM 85.9% and 1.2%. The mortality ratio, at 10 years, between low-risk and high-risk patients was 22.2 for the AMES, 25.0 for the MACIS and 41.8 for the TNM system. The proportion of explained variance in the Cox model was 16.3 for the AMES, 30.0 for the MACIS taken as a conitinuous variable and 28.9 for the TNM stage. The TNM stage was on average superior to the MACIS or AMES score in predicting cancer-specific mortality of patients with papillary thyroid carcinoma. This may be explained by the fact that the TNM system includes the prognostic effect of nodal metastases, which is included in neither the MACIS nor AMES systems.

Predicting fatal outcome in the early phase of severe acute pancreatitis by using novel prognostic models.

BACKGROUND/AIMS: Survival in acute pancreatitis and particularly in severe acute and necrotizing pancreatitis is a combination of therapy-associated and patient-related factors. There are only few relevant methods for predicting fatal outcome in acute pancreatitis. Scores such as Ranson, Imrie, Blamey, and APACHE II are practical in assessing the severity of the disease, but are not sufficiently validated for predicting fatal outcome among patients with severe acute pancreatitis. The aim of this study was to construct a novel prediction model for predicting fatal outcome in the early phase of severe acute pancreatitis (SAP) and to compare this model with previously reported predictive systems. METHODS: Hospital records of 253 patients with SAP were retrospectively analyzed. 234 patients with adequate data were included to the test set to construct five logistic regression and three artificial neural network (ANN) models. Two models were tested in an independent prospective validation set of 60 consecutive patients with SAP and compared with previously reported predictive systems. RESULTS: The prediction model considered optimal was a logistic model with four variables: age, highest serum creatinine value within 60-72 h from primary admission, need for mechanical ventilation, and chronic health status. In the validation set, the predictive accuracy, determined by the area under the receiver operating characteristic curve value, was 0.862 for the chosen model, 0.847 for the ANN model using eight variables, 0.817 for APACHE II, 0.781 for multiple organ dysfunction score, 0.655 for Ranson, and 0.536 for Imrie scores. CONCLUSIONS: Ranson and Imrie scores are inaccurate indicators of the mortality in SAP. A novel predictive model based on four variables can reach at least the same predictive performance as the APACHE II system with 14 variables.

Long-term health-related quality of life in survivors of severe acute pancreatitis.

OBJECTIVE: To evaluate the health-related quality of life (HRQL) and postdischarge outcome after severe acute pancreatitis. DESIGN AND SETTING: Observational study in a department of surgery (surgical and general intensive care unit) in a tertiary care hospital. PATIENTS AND PARTICIPANTS: Of 283 patients with severe acute pancreatitis 211 survived; during a follow-up period an additional 27 died. The Rand 36-item Health Survey with accessory question was mailed to 174 eligible patients. The final study population comprised 145 patients (83% response rate). Age- and sex-matched Finnish population scores were compared with the study population; accessory questions were analyzed separately. RESULTS: No clinically significant differences were found in long-term HRQL between study patients and the general population. Of the 145 patients 87% returned to work, 27% suffered recurrent pancreatitis, and 43% developed diabetes. Of 113 patients with alcohol-induced severe acute pancreatitis 30% were abstinent and 28% problem drinkers, alcohol-dependent, or alcoholics. CONCLUSIONS: Up to 13% of severe acute pancreatitis patients surviving initial hospitalization die within a few years. Among the survivors long-term HRQL is comparable to that of the normal population. The majority return to work and reduce their alcohol consumption markedly.

Multiple organ dysfunction associated with severe acute pancreatitis.

OBJECTIVE: To compare three different multiple organ dysfunction scores in predicting hospital mortality rates and to discover which one best assesses organ dysfunction/failure in patients with severe acute pancreatitis in a general intensive care unit. DESIGN: Retrospective, observational study. SETTING: Surgical department and a ten-bed general intensive care unit in a tertiary care hospital. PATIENTS: Among the 178 consecutive patients admitted to the surgical department with severe acute pancreatitis from 1994 to 1998, 113 patients treated in the general intensive care unit underwent study. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Clinical and laboratory data were collected during a period of 35 days. Acute Physiology and Chronic Health Evaluation (APACHE) II, Multiple Organ Dysfunction (MOD) score, Sequential Organ Failure Assessment (SOFA) score, and Logistic Organ Dysfunction (LOD) score were calculated and compared regarding hospital mortality rate. In addition, daily maximum score and a total maximum score (sum of the highest values for each organ dysfunction) were calculated for all three scores. The area under the receiver operating characteristic curve was used as a measure of accuracy of the scores. The highest accuracy was revealed with daily maximum scores with the area under the receiver operating characteristic curve 0.847 for SOFA, 0.844 for MOD, and 0.836 for LOD. According to the maximum SOFA score, the highest mortality rate was associated with liver (83%, p <.001) and renal (63%, p <.001) failures. The mortality ratio with two organ failures ranged from 50% to 91%. The highest mortality rate (91%) was for a combination of hepatic and renal failure. In multiple logistic regression analysis, only hepatic, renal, and cardiovascular failure and previous cardiovascular medication were independent risk factors for hospital mortality. CONCLUSION: In patients with severe acute pancreatitis, organ dysfunction scores (MOD, SOFA, LOD) show good accuracy, comparable with APACHE II in predicting hospital mortality. The maximum daily organ dysfunction scores were simple and useful in assessing multiple organ dysfunction and in predicting hospital mortality rates of patients with severe acute pancreatitis.