Incidence and reversibility of organ failure in the course of sterile or infected necrotizing pancreatitis.

BACKGROUND: Multiple organ failure (MOF) and infected necrosis are both considered severe adverse events during the course of necrotizing pancreatitis. HYPOTHESIS: The incidence of MOF and its reversibility in patients with necrotizing pancreatitis are influenced by the presence or absence of infected necrosis. DESIGN: Case series. SETTING: Intensive care, university teaching hospital. PATIENTS: Forty-three patients with necrotizing pancreatitis and failure of at least 1 organ were prospectively included. MAIN OUTCOME MEASURES: Organ failure defined according to the Goris classification; MOF defined by the simultaneous occurrence of 3 organ failures and graded with an MOF score. Microbial status of necrosis was assessed by percutaneous or intraoperative sampling. Surgical drainage was performed in patients with infected necrosis, whereas sterile necrosis was managed conservatively. RESULTS: Infected necrosis occurred in 27 patients (63%). The mean (+/-SEM) number of organ failures was greater in cases of infection (3.6 +/- 1.1 vs 2.6 +/- 1.5; P =.02). Multiple organ failure occurred more frequently in cases of infected necrosis (23/27 vs 7/16; P<.01) and was responsible for an increased mortality in this subgroup (33% vs 6%; P =.1). The severity of MOF graded by the MOF score was related to the bacteriologic status of necrosis. CONCLUSIONS: The higher mortality commonly attributed to MOF in patients with infected necrosis appears to be due to a higher frequency and an increased severity of MOF. Conservative management in patients with severe necrotizing pancreatitis and sterile necrosis complicated by MOF is supported by the high reversibility rate of MOF and the low mortality rate observed in this series.

Association between nasal carriage of Staphylococcus aureus and infection in liver transplant recipients.

We reviewed the records of 87 patients who underwent liver transplantation and who were screened by use of nasal swabs on the day before surgery. Twenty-four patients harbored methicillin-susceptible Staphylococcus aureus (MSSA), and 8 harbored methicillin-resistant S. aureus (MRSA). MSSA infection occurred in 3 (12.5%) of 24 MSSA carriers and in 2 (3.2%) of 63 noncarriers (nonsignificant). In contrast, MRSA infection occurred more frequently in MRSA carriers (7 [87.5%] of 8) than in MRSA noncarriers (8 [10.1%] of 79; P<.001). Nasal carriage of MRSA is associated with a very high risk of MRSA infection in liver transplant recipients.

[Mediastinal and cervical diffusion of necrosis infiltration in acute pancreatitis]. / Diffusion médiastinale et cervicale d'une coulée de nécrose au cours d'une pancréatite aiguë.

Thoracic complications of acute pancreatitis are mainly caused by the rupture of the main pancreatic duct leading to the diffusion of pancreatic juice into the mediastinum. Occasionally, esophagus or respiratory tract may also be involved. We report here the case of a 51-year-old man with acute alcohol-related pancreatitis who developed mediastinal and cervical infiltration through a wirsungo-mediastinal fistula caused by the leak of the main pancreatic duct which was successfully treated by splenopancreatectomy.

Diagnosis and conservative management of intrathoracic leakage after oesophagectomy.

BACKGROUND: Although intrathoracic leakage is a major complication of oesophagectomy, precise data concerning diagnostic features and results of conservative treatment are lacking. METHODS: From 1986 to 1994, 409 oesophagectomies with stapled oesophagogastrostomy were performed, including 358 Lewis-Tanner and 51 Sweet procedures. A water-soluble contrast swallow was routinely performed on day 7 or later, before oral intake was begun. All patients except one received conservative non-surgical treatment, including nutritional support and perianastomotic drainage. RESULTS: Leaks were diagnosed in 38 patients (9.3 per cent). The leakage rate was 7.8 per cent after the Lewis-Tanner procedure and 20 per cent after the Sweet procedure (P < 0.01). Eleven patients had no symptoms. Seven of the 27 patients with symptoms had a contrast swallow that was normal, and subsequently developed a confirmed fistula after the onset of oral intake. Five patients had to undergo reoperation. All asymptomatic patients and 18 symptomatic patients recovered. Nine patients died, mainly from multiple organ failure, including three who had reoperation for resection of the gastroplasty. CONCLUSION: The potential presence of clinically silent fistula and the deleterious role of oral intake still justify routine detection of leakage after oesophageal resection. Conservative treatment results in survival with preservation of the gastroplasty in most patients, unless multiple organ failure occurs.

Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy.

BACKGROUND: The management of chylothorax complicating oesophagectomy remains controversial. Even if medical management alone can be successful, some authors advocate early reoperation. The aim of this retrospective study was to identify the clinical variables associated with a high probability of full recovery with medical treatment. METHODS: Among 850 Lewis procedures performed for oesophageal carcinoma, 23 patients (2.7 per cent) developed postoperative chylothorax despite systematic preventive ligation of the main thoracic duct. Patients who responded to conservative management were compared with those requiring reoperation for preoperative radiotherapy, unilateral versus bilateral pleural effusion, delay of occurrence of the chylothorax, and ratio of mean chylous output to body-weight 1 and 5 days after its onset. RESULTS: Conservative management was successful in 14 patients with a mean(s.d.) delay of 12(5) (range 7-21) days and there were no hospital deaths. Reoperation was necessary in nine patients; there were two postoperative deaths and no recurrence of the chylothorax. The only significant difference between reoperated and medically treated patients was the mean(s.d.) chylous output at day 5: 23.5(16.6) versus 6.7(5.5) ml per kg body-weight (P< 0.001). At this time, the output was less than 10 ml/kg in 12 of 14 patients in whom medical treatment was successful (sensitivity 86 per cent), and equal to or greater than this cut-off value in all the patients who underwent reoperation (specificity 100 per cent). CONCLUSION: The ratio of chylous output to body-weight on the fifth day after the onset of a chylothorax complicating oesophagectomy seems to reliably predict the success of continuing medical treatment.

Morphological aspects of necrosis as a guideline for treatment of necrotizing pancreatitis. A brief report about 50 patients.

In a retrospective study, 50 patients with obvious necrotizing pancreatitis (NP) were allocated in four groups according to the morphological aspects of the necrosis. Appearance of ascite (N1), extrapancreatic spread of necrosis towards neighboring organs (N2), a large amount of necrosis (N3), and infected necrosis (N4), appears to be an easy and useful guideline for the management of NP patients. Organ failures (72%) and mortality rate (36%) are higher when the process is infected. In the other groups, organic dysfunctions were frequent, but all the patients except one survived. The majority (80%) of patients were operated on. Only 20% of patients had successful nonsurgical treatment and they were in N3 group. This percentage may increase through a morphological approach to treating necrosis, with the use of endoscopic treatment for the disruption of pancreatic duct, and better accuracy in the management of patients with noninfected necrosis, whenever organ failures are present.

[Is early extubation after surgery for esophageal cancer possible?]. / L'extubation précoce après chirurgie du cancer de l'oesophage est-elle possible?

In a series of 50 patients undergoing elective oesogastrectomy through a laparotomy and a right thoracotomy, the avoidance of overnight ventilatory support was made possible by the agreement of anaesthetists and surgeons on suitable policies. The attempt to extubate the patients immediately postoperatively differentiated two groups. For the first group (32 patients; 64%), early extubation could be performed and only one patient was reintubated and required prolonged ventilation. A second group comprised 18 patients who could not be extubated early (36%). For most of the patients in this second group extubation was only delayed until the next day, and recovery was otherwise uneventful. In three cases, however, pulmonary atelectasis with infection was a major problem, and these patients required broncho-endoscopies, and prolonged ventilatory support. Nevertheless, morbidity and mortality after oesophagectomy were significantly reduced in this series, compared with a previous study in the same hospital. Careful postoperative assessment of the patient is essential. The main factors leading to the decision for early extubation appeared to be: absence of serious cardiovascular history, absence of peroperative surgical complications, adequate rewarming, normal chest X-ray, and the presence of clinical criteria for extubation along with adequate arterial blood gases. If the above criteria can be achieved, then early extubation should be routine and can be safely performed in the majority of cases.

[A surgical etiology of respiratory distress in necrotizing pancreatitis: pancreato-bronchial fistula. 3 cases]. / Une étiologie chirurgicale de la détresse respiratoire au cours de la pancréatite nécrosante: la fistule pancréatico-bronchique. Trois observations.

Adult respiratory distress syndrome (ARDS) is a frequent feature in acute pancreatitis, but précise etiology of hypoxemia remains unclear. Determinations of lipase and amylase levels are made in samples of bronchial secretion, in three intubated patients receiving assisted ventilation for severe hypoxemia occurring in the course of pancreatitis. This determination appeared to be valuable to incriminate the responsibility of a pancratico-bronchial fistula. In the first case, emergency laparotomy was able to show the fistulous track. In the second described case, an endoscopic retrograde pancreatography was performed, showing a fistula from pancreatic body to left bronchial tree. In the third case, the presence of a bronchial fistula was proved by a fistulography trough the abdominal pancreatic necrosis. A decrease of arterial PO2 followed pancreatography and fistulography. The surgical treatment was splenopancreatectomy, necrosectomy associated with left pulmonary lobectomy, and necrosectomy with colonic diversion. In the third case, pancreatico-bronchial fistula was the final evolution of an infected intra-abdominal necrosis, despite multiple surgical drainages. In the first and second cases, surgical treatment obtained a prompt and uneventful recovery. Few published cases of pancreatico-bronchial fistulae are reported. A retrospective study of 12 ARDS was made among 40 patients underwenting laparotomy, with an objective recognition of necrotizing pancreatitis, from 1980 to 1987. A pancreatico-bronchial fistula could be incriminated in three cases of these 12 ARDS. Such a prevalence of 25% has to be reevaluated after serial determinations of lipase and amylase levels in bronchial samples of intubated patients suffering from ARDS in the course of pancreatic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aseptic tracheobronchial aspiration]. / Aspiration trachéobronchique aseptique.

Nosocomial lung superinfection is a frequent feature in ICU hospitalized patients. Up to 60 per cent of these patients may develop pneumonia, depending on the severity of their underlying disease. Necessary tracheobronchial irrigations and succions expose patients requiring mechanical ventilation to a risk of bacterial contamination by water containing infections particles. The "no touch method", elsewhere described, using disposable material and serious asepsis, try to diminish rate of one of the risk factors for acquired pneumonia. The use of a single-dose plastic bottle of sterile normal saline (solution ophta-ORL Faure) for tracheal irrigation is a clean and very low cost-price method, that minimize the risk of extrinsic contamination.

[Acute respiratory distress caused by pancreatico-bronchial fistula in acute pancreatitis. Apropos of 2 cases]. / Détresse respiratoire aiguë par fistule pancréatico-bronchique au cours d'une pancréatite aiguë. A propos de deux observations.

The adult respiratory distress syndrome (ARDS) is a frequent feature of acute pancreatitis. Amylase and lipase values were determined in samples of bronchial secretions in two patients with endotracheal intubation and under supportive ventilation for severe hypoxemia occurring during the course of acute pancreatitis. A pancreatico-bronchial fistula was suggested in both cases. In one case, an endoscopic retrograde pancreatography was performed and demonstrated a fistula between the pancreatic body and the left bronchial tree. Arterial pH values decreased following pancreatography. Splenopancreatectomy was performed in one case, and necrosectomy associated with left pulmonary lobectomy in the other. Documented cases of pancreaticobronchial fistulas have been rarely reported to date. A retrospective study of 10 patients with ARDS was made among 32 patients undergoing laparotomy for objectively recognized necrotizing pancreatitis. A pancreatico-bronchial fistula could be incriminated in three cases. This 30 p. 100 prevalence has to be re-evaluated in the light of serial determinations of amylase and lipase levels in patients with ARD and endotracheal intubation in the course of pancreatic disease. In these patients, high levels of amylase and lipase in bronchial secretions, the use of iso-osmolar X-ray colloids could be helpful in protecting the alveolar membrane against osmolar injury during pancreatography.

[pH and the bacteriology of gastroplasties after esogastric resection]. / pH et bactériologie des gastro-plasties après résection oeso-gastrique.

A study of pH of digestive fluid in 24 patients six days after esophagogastric resection (EGR) showed conservation of acidity (pH: 3 or less) in one-thirds of cases. Immediate postoperative course was invariable with respect to incidence of pneumopathy and fistulae. Fungal infection is almost a constant finding in digestive grafts together with microbial pullulation, with a linear relation to pH. Ecology of germs was that of digestive flora of patients with obstruction, selected by the antibiotic cover administered. Group D streptococci and Gram negative bacilli were usually resistant to cephalosporins. Regurgitation pneumopathy therefore requires modification of antibiotic therapy and possible antifungal treatment. When functional disturbance is provoked by EGR, as for example a reflux syndrome; only those patients (1/3) with a pH of 3 or less can obtain relief from treatment with antacids.

[In vitro activity of the combination ticarcillin-clavulanic acid on bacterial isolates in surgery]. / Activité in vitro de l'association ticarcilline-acide clavulanique sur les bactéries isolées en chirurgie.

The in vitro activity of ticarcillin in combination with clavulanic acid was tested, by disc diffusion, against 1,380 clinical bacterial isolates and was compared with that of ticarcillin alone. 83.8% of the isolates were susceptible to ticarcillin + clavulanic acid, whereas 56.6% were susceptible to ticarcillin alone. Minimal inhibitory concentrations (MIC) of ticarcillin in the presence of 4 micrograms/ml of clavulanic acid were determined against 157 ticarcillin resistant (MIC greater than 128 micrograms/ml) but ticarcillin + clavulanic acid susceptible strains of Gram negative bacilli and against 20 strains of beta-lactamase producing Staphylococcus aureus. With the addition of clavulanic acid, MICs of ticarcillin were respectively less than or equal to 16 micrograms/ml and less than or equal to 64 micrograms/ml for 50 and 90% of the Gram negative bacilli. All the Staphylococcus aureus were inhibited by concentrations of ticarcillin less than or equal to 1 microgram/ml.

[Pulmonary complications after gastrografin inhalation during radiographic control of esophageal anastomosis]. / Complications pulmonaires après inhalation de gastrografine lors du contrôle radiologique des anastomoses oesophagiennes.

Tracheal penetration of water soluble contrast media (gastrografin) for X-ray control, after gastro-oesophageal anastomosis, resulted in acute pulmonary oedema in two patients. In this type of surgery, mediastinal dissection was responsible for recurrent nerve injury. Inhalation was due to this recurrent nerve palsy. The pulmonary oedema could be related to gastrografin high osmolarity. Therefore, to prevent this complication, previous laryngeal cavity examination is recommended before carrying out the X-ray investigations. In case of recurrent nerve paralysis, barium sulphate or lipiodol should be preferred because of their lack of effect on the lungs.

[Hemothorax during subclavian catheterization. Risk factors not be neglected]. / Hémothorax au cours du cathétérisme sous-clavier. Des facteurs de risque à ne pas négliger.

In the post operative course of a peritonitis, the need for a central venous catheter. A 800 ml hemothorax in the left pleura occurred. It could not be relieved with a chest-tube, and had to be evacuated through a thoracotomy. The risk factors to be considered in this case were sequellae of an inner third clavicle fracture and an arterial hypertension; although the patient was given a minimal dose of calcium heparinate.