Journal of the Pancreas最新文献

Context: The surgical treatment of necrotizing pancreatitis includes percutaneous drainage of acute necrotic collections and sequestrectomy in the late phase of the disease.

Objective: The aim of the study was to compare the conventional open necrosectomy (CON) approach with the alternative focused open necrosectomy (FON) approach in patients with infected necrosis and progression of sepsis.

Methods: Patients with acute necrotizing pancreatitis were included in the study prospectively from January 2004 to July 2014. All patients had been admitted with the first or a new episode of disease. Symptomatic large fluid collections were drained percutaneously. The step-up approach was used in patients with several distant localizations of infected necrosis. The methods were analysed by comparing the individual severity according to the ASA, APACHE II and SOFA scores, infection rate, postoperative complication rate and mortality.

Results: A total of 31 patients were included in the FON group and 39 in the CON group. The incidence of infection was similar in groups. More ASA III comorbid conditions, a higher APACHE II score, a more frequent need for renal replacement therapy was observed in the CON group. The postoperative complication rate was in the range of 32% to 44%; mortality reached 6.5% in the FON group and 12.8% in the CON group.

Conclusions: Comorbid conditions, organ failure, and infection are the main risk factors in patients with necrotizing pancreatitis. The step-up approach and perioperative ultrasonography navigation improves the clinical outcome and reduces the extent of invasive surgical intervention in patients unsuited to other minimally invasive procedures.

Context: Although unripe plantain (Musa paradisiaca) and ginger (Zingiber officinale) are used as single plants to manage diabetes mellitus in Nigeria, the possibility of combining them in a typical diabetic diet and the glycemic response elicited as a result of such combination has not been investigated.

Objective: To determine the effect of unripe plantain and ginger on serum total proteins, albumin, creatinine and urea levels of streptozotocin induced diabetic rats.

Methods: Twenty four male albino rats were used and were divided into 4 groups of 6 rats each. Group 1 (non-diabetic) received standard rat feeds; Group 2 (diabetic) received standard rat feeds; Group 3 received unripe plantain pellets and Group 4 received unripe plantain+ginger pellets.

Results: There were significant increases (P=0.045) of both serum urea and creatinine, but significant decreases (P=0.045) of both serum total protein and albumin levels, in Group 2 rats compared with Group 1. There were significant decreases (P=0.033) of both serum urea and creatinine levels of Group 3 and 4 rats compared with Group 2. In addition, there were significant increases of both serum total protein and albumin levels (P=0.033) in Group 3 rats compared with Group 2, but the comparison of serum total protein and albumin levels between Group 4 and Group 2 did not reach the significant level (P=0.056 and P=0.065 for serum total protein and albumin levels, respectively.

Conclusion: Combination of unripe plantain and ginger at the ratio used in the management of renal dysfunction in diabetics was not very effective compared with unripe plantain alone.

Context: Agenesis of the dorsal pancreas is a rare congenital anomaly which can be detected either incidentally during imaging or encountered during investigation for pancreas related pathologies such as pancreatitis or diabetes mellitus. Few associations of this condition with heterotaxy syndrome, pancreatic tumors and congenital heart disease have been described.

Case report: We report a novel association of genitourinary anomalies in a case of complete dorsal pancreatic agenesis not previously described in the literature.

Conclusion: Knowledge about dorsal pancreatic agenesis is essential for radiologist in patients presenting with unexplained pain abdomen and its association with various conditions may help radiologist in assisting clinician in management of these patients.

Context: Pancreaticoduodenectomy is the gold standard for patients with resectable periampullary carcinoma. The protection of the anastomosis by positioning of an intraluminal stent is a technique used to lower the frequency of anastomotic fistulas. However the use of anastomotic stents is still debated and stent related complications are reported.

Case report: A fifty-three-year old male underwent pancreaticoduodenectomy (PD) for a T2N0 periampullary carcinoma with a pancreaticojejunal (duct to mucosa) anastomosis protected by a free floating 6 Fr Nelaton stent in the Wirsung duct. Twenty-three months after surgery the patient accessed Emergency Department for severe abdominal pain associated to temperature, high white blood cell count and an significant increase in C reactive protein. Method Abdominal CT scan shown the presence of a tubular stent in the mesogastrium/lower right quadrant. No evident free intra-abdominal air was detected. The patient was submitted to explorative laparotomy. After debridement for localized peritonitis the Nelaton trans anastomotic stent was found in the abdomen. There was no evidence of bowel perforation, but intestinal loops covered with fibrin and suspect for impending perforation were resected.

Conclusion: There is a lack of evidence about the true rate of post-operative complications related to pancreatic stenting. We believe that in patients presenting with abdominal pain or peritonitis that previously underwent PD with stent-guided pancreaticojejunal anastomosis, the hypothesis of stent migration should at least be taken into consideration.

Context: Pancreaticoduodenectomy in partially-gastrectomized patients presents some peculiarities of the reconstructive phase. Above all, in B II and Roux-en-Y partial gastrectomies, a gastric re-resection with a redo gastrojejunal anastomosis should be avoided because it is often needlessly time-consuming and risky. In our series of 7 consecutive patients, either one of two reconstruction methods was used, depending upon the length of the pre-existing afferent loop.

Case reports: In order to better illustrate this strategy, two cases of carcinoma of the duodenal papilla are reported. Both of the patients had previously undergone partial gastrectomy with B II reconstruction for peptic ulcers. Both were admitted to our hospital with a past history of jaundice. However, whereas in Case #2 a sufficiently long pre-existent afferent loop could be utilized for the pancreatic and bile duct anastomoses, in Case #1 a shorter afferent loop was removed and the efferent loop was utilized for the anastomoses. The postoperative course was uneventful in both patients.

Conclusions: This reconstructive strategy for pancreaticoduodenectomy in gastrectomized patients, which uses either of the methods described above, has produced good results in our series of 7 patients and appears to be rational and straightforward.

Context: Acute pancreatitis can be triggered by a variety of factors ranging from short lasting to sustained disruptions. It is plausible that the characteristics and course of disease differ among etiologies. Data distinguishing characteristics of patients with pancreatitis of biliary, alcoholic, idiopathic or other origin are scarce and conflicting.

Objective: To compare patients' characteristics, baseline parameters on admission, and outcome in patients with an episode of acute pancreatitis in whom the etiology was thoroughly determined.

Design: Retrospective study.

Setting: Single center.

Patients: Three-hundreds and 91 consecutive episodes of acute pancreatitis through the years 2008 to 2011.

Main outcome measures: Gender, age, body mass index, Charlson comorbidity index, history of pancreatitis, heart rate, blood pressure, plasma lipase, hematocrit, plasma creatinine, white blood cell count, rate of persistent organ failure and necrosis, maximum C-reactive protein, duration of hospitalization, mortality.

Results: There were marked differences between the groups. Biliary etiology was associated with higher age and body weight, female predominance, higher plasma lipase, and a favourable outcome. Alcoholic etiology had male predominance, a tendency for initial hemoconcentration, a lower plasma lipase, and the highest rate of necrosis. Idiopathic etiology had the highest rate of persistent organ failure and the highest mortality.

Conclusions: Biliary, alcoholic and idiopathic acute pancreatitis should be treated as distinct entities. While alcoholic episodes have the highest risk of necrosis, the worst outcome was observed in the idiopathic group. Hence, finding no causality for an episode of acute pancreatitis after thorough investigation might be a predictor for poor outcome. Larger studies are warranted to confirm this.

Context: Levamisole-contaminated cocaine is an increasingly reported cause of vasculitis and immunologic abnormalities in cocaine abusers. The systemic effects of vasculitis are commonly seen in the dermatologic, hematologic and renal systems but rarely the gastrointestinal system.

Case report: We present an atypical case of cocaine-induced vasculitis presenting initially as an acute pancreatitis and then rapidly progressing to involve multi-organ systems over the next couple of weeks.

Conclusion: Internists should recognize that acute pancreatitis can present as an atypical and rare initial systemic manifestation of cocaine-induced vasculitis.

Context: The triad of acute pancreatitis, hypertriglyceridemia and diabetes is a rare occurrence.

Case report: A previously well 19-year-old male presented to the emergency department with 24-hour history of epigastric pain, associated with polyuria and nausea. Biochemical markers showed the presence of hyperglycemia (blood sugar level 15 mmol/L) and ketonemia (5.3 mmol/L). Further investigation revealed severe hypertriglyceridemia (4,009 mg/dL) and elevated lipase (1,714 U/L). Abdominal ultrasound confirmed the diagnosis of acute pancreatitis. He was transferred to intensive care, where he received i.v. hydration, insulin and dextrose infusion. His metabolic derangements gradually resolved. His glycosylated hemoglobin was 13%, indicating the presence of chronically elevated blood sugars.

Conclusion: The possible pathophysiology and management of this unusual triad: diabetic ketoacidosis, hypertriglyceridemia and acute pancreatitis, are explored in this paper.