Surgical treatment of chronic pancreatitis--a 14 years experience^-www.drkeyurbhatt.in*

Stroescu C, Dima S, Scarlat A, Ivanov B, Bouaru O, Ionescu M, Vasilescu C, Popescu I.

Centrul de Chirurgie Generală si Transplant Hepatic, Institutul de Boli Digestive si Transplant Hepatic Fundeni, Bucureşti. cezar.stroescu@gmail.com

Abstract

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or in the presence of complications of the disease.

AIMS: This study evaluates a single-center experience with operative management of chronic pancreatitis over a period of time of 14 years, regarding indication, surgical technique, early and late results.

PATIENTS AND METHODS: The records of 265 consecutive patients who underwent surgery for chronic pancreatitis between 1995 and 2008 were retrospectively reviewed and analyzed. Long-term outcomes were assessed by patient survey, with a median follow-up of 40 months.

RESULTS: 265 patients underwent 275 operations for chronic pancreatitis with the main indication abdominal pain (46.8%), followed by suspected malignancy in 24.8% and recurrent episodes of acute pancreatitis in 18.6%. Resection procedures 54.5% (150), drainage procedures 1.09% (3), bypass and denervation procedures 44.36% (122) and exploratory laparotomy 3.27% (9) were performed with an overall morbidity of 22% and an in-hospital mortality rate of 2.64%. After a median follow-up of 40 months survival information was available for 137 patients (51.69%) with a 5-and actuarial survival rate of 74.7% and quality of life improvement in most patients, especially in the resected group.

CONCLUSION: Our results suggest that in chronic pancreatitis the type of surgery has to be individualized in each patient (resection VS drainage) and organ preserving operations are safe and effective in providing long-term pain relief and in treating CP-related complications

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SMA Thromboembolism^-www.drkeyurbhatt.in*

COMPLICATIONS:

Because of the high prevalence of atherosclerosis, one of the most common complications involves MI. 

Acute renal failure in the immediate postoperative period can be prevented by keeping the patient well hydrated and administering mannitol before the aorta is cross-clamped.

Other possible complications include bleeding, infection, bowel infarction, prolonged ileus, and graft infection.

Follow-up

• Because of the high likelihood of concomitant vascular disease in the rest of the arterial tree, patients must be closely monitored.
• Any laboratory or radiologic examinations not previously performed in the hospital are performed in an outpatient setting.
• The patient should have frequent visits to monitor the prothrombin time, activated partial thromboplastin time, and international normalized ratio to assure proper anticoagulation.

Outcome and Prognosis

Because of the delay in diagnosis, mesenteric artery ischemia is typically a lethal disease, with a mortality rate of 45-65%. 

When more than half the bowel is removed, mortality rates of up to 80% have been reported. 

A review of 45 studies demonstrated that the prognosis for patients with acute mesenteric ischemia differs when one looks at the etiology. 

Mortality rates are highest for patients with arterial thrombosis (70-87%), followed by nonocclusive mesenteric ischemia (70-80%), arterial embolism (66-71%), and venous thrombosis (44%). 

Mortality rates have been improving over the last 4 decades.

Future and Controversies

Over the past 20 years, diagnosis and treatment of mesenteric ischemia has advanced only minimally.

• In a review of 57 cases, only 18% of patients were properly diagnosed with mesenteric ischemia before operation or death. Of the 57 patients in this review, 46 died.
• Some advances in diagnosis include magnetic resonance imaging and laser Doppler flowmetry. Preliminary results for these modalities are encouraging.
• Percutaneous transluminal angioplasty with stenting has proven valuable as a treatment option in selected patients. A study demonstrated that, at 6 months, patency was equivalent between stenting and open revascularization; however, freedom from symptoms was less in the stented group.
• As previously mentioned, similar results were found in a study by Kougias et al, in which the effectiveness of balloon angioplasty and/or endovascular stenting (48 patients, 58 vessels) was compared with that of open revascularization (96 patients, 157 vessels) in the treatment of chronic mesenteric ischemia.The investigators determined that members of the endovascular group had a shorter hospital stay (3 days) than did patients in the open revascularization group (12 days, P <0.03) and that the 30-day mortality rate, frequency of inhospital complications, and 3-year cumulative survival rate were the same for both groups.
• Three years after the procedures, however, cumulative freedom from recurrent symptoms was found in a higher percentage of open revascularization patients than in members of the endovascular group (66% vs 27%, P <0.02). The authors suggested that this was because the percentage of patients who underwent a 2-vessel procedure rather than a 1-vessel intervention was higher in the open group than in the endovascular one.
• Some authors recommend a trial of thrombolytic therapy if patients can be treated within 8 hours of presentation and do not have signs of bowel necrosis or peritonitis.If no evidence of improvement is noted within 4 hours, patients should undergo exploration.
• Local tissue plasminogen activator may reduce the amount of bowel requiring resection.

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Obscure G I BLEEDING^-www.drkeyurbhatt.in*

GASTROINTESTINAL ENDOSCOPY,  VOLUME 58, NO. 5, 2003

For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion.

OGIB comprises approximately 5% of all patients with GI bleeding, with the majority of lesions located in the small intestine. (B)  Common small intestine lesions include angiodysplasia, tumors, NSAID enteropathy, and Meckel’s diverticulum-associated ulcers. (B)  Obscure GI bleeding can either be occult, manifesting

as IDA, or overt, manifesting as hematochezia or melena. (C)  Once upper and lower GI lesions have been

excluded by carefully performed repeated EGD and colonoscopy to the terminal ileum, examination

of the small intestine is warranted. (C)  Diagnostic tests include PE, CE, barium studies (SBFT or enteroclysis), nuclear medicine testing, angiography, and IOE. (B) While large published comparative trials are lacking, PE has been shown to be superior to EGD and SBFT, and CE is similarly superior to SBFT and possibly to PE as well. (A) Choice among tests has yet to be established and will be dictated by the clinical scenario, availability, and local expertise. (C) Intra-operative enteroscopy is reserved for patients with refractory severe recurrent bleeding, transfusion dependency, or those in whom a lesion is identified that cannot be treated by using PE or colonoscopy with ileoscopy. (C)

 

Once a diagnosis is established, appropriate medical and/or surgical therapy must be individualized. (C)

American Society For Gastrointestinal Endoscopy

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CASE: Stab in abdomen with holo visceral injury + Missed pancreatic injury leading to^-www.drkeyurbhatt.in*

38 yrs male with stab in abdomen before one month...with peritonitis ...explored and found to have Transverse colon and gastric perf. ...closed primarily....improved gradually.....

developed distension and persistant fever....G/C detoriating gradually.....CECT was done....found to have RHC collection ? biliary?
next day Per Cut Drain was kept....draining bile...ERC tried but papilla was not located...

later Referred for biliary fistula to me...

As the fistula was controlled with drain around 200ml of bile/day...and pt was clinically improving and taking oral diet..passing stool....kept conservatively....
Unfortunately pt took DAMA....re admitted after 5days with distension of abdomen and drain out put of >1400ml/day.....? high out put fecal fistula ......and pt started detoriating fast with sepsis and shock...

CECT was repeated ... Revalled multiple intra abdominal collection and peri pancreatic necrosis...

Taken up for surgery.... Intra abdominal collections drained....bowel was healthy though out..
Drain tract explored from rt flank...and RETROPERITONEAL NECROSECTOMY was done thorough lavage and Laparoscopic (retro peritoneal) drainage of dirty material was done...

Remained on venti for 2.5 days ....now taking oral diet ..passing stool...POD 6 (today) out of ICU. ..having biliary fistula in Rt flank drain which is retro peritoneal and controlled one...TLC  normal...sepsis controlled shifted to ward...now one drain out and patient having a low biliary fistula..<30 ml /day only Rt drain... fit for discharge (24.1.11)....pt discharged.....on 27.1.11..(POD 21)

healing necrosectomy site in Rt flank

ADVANTAGE OF RETRO PERITONEAL NECROSECTOMY....

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CASE: TRAUMATIC TRANSECTION OF D-J FLEXURE^-www.drkeyurbhatt.in*

18 yr male with blunt trauma head and abdomen
with Normal CECT Brain.
Pneumoperitoneum and bowel perforation on CECT abdomen.

on exploration almost complete transaction of DJ flexure was found....with peritonitits...

after thorough lavage both the ends of transaction were trimmed 1.5 cm and Single layer Extra Mucosal Interrupted anastomosis done....RT placed in D-2.. and A feeding Jejuonostomy was done...with drainage...

Pt is doing well on POD 6..Today.. tolerating sips orally and Jejuonostomy feeding as well...Out of Sepsis...

DISCHARGED TODAY WITH NORMAL DIET..AND HEALTHY WOUND..27.1.11.

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