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.

BACKGROUND:Splanchnic thrombosis is a surgical challenge in liver transplantation (LT). The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution.AIM:The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution.PATIENTS AND METHODS:Between 1999 and 2004, 366 liver transplants were performed in 335 patients. Forty-two patients [12.5%: portal vein thrombosis (PVT) group] had portal thrombosis at the time of LT. We analyzed the technical aspects and compared their evolution with a group of patients without portal thrombosis (n = 293; no-PVT group). Retransplantations were excluded.RESULTS:Of the 42 patients with thrombosis, 18 had partial thrombosis and 16 complete thrombosis [six included the proximal superior mesenteric vein (SMV) and in two the whole splanchnic system]. In 12 cases, usual T-T anastomosis was performed and in 16 cases a thrombectomy was carried out; there were five cases of anastomosis at confluence of the SMV, five cases of anastomosis to a collateral vein, three cases of venous graft, and one case of cavoportal hemitransposition. The operative time was higher in PVT group (417 +/- 103 min vs. 363 +/- 83; p = 0.0005), as RBC transfusion (2.4 +/- 3.1 vs. 1.9 +/- 2.3; p = 0.04), and hospital stay (20.9 +/- 14.9 d vs. 15.1 +/- 10.6; p = 0.002). However, there were no differences in hospital mortality (4% vs. 7.8%; p = 0.98), primary dysfunction (4.8% vs. 7.8%; p = 0.44), or three-yr-actuarial survival (75% vs. 77%; p = 0.95). The incidence of post-transplant thrombosis was higher in the PVT group (15% vs. 2.4%; p = 0.0005).CONCLUSIONS:Portal thrombosis is associated with greater operative complexity and rethrombosis, but has no influence on overall morbidity and mortality.

Objective: Although diverticulitis is the most common cause of large bowel perforation, other disease may result in left colonic peritonitis. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with different causes of nondiverticular left colonic perforations.Patients and methods: From January 1992 to September 2000, 212 surgical patients underwent emergency operation for distal colonic peritonitis. Perforations were caused by diverticulitis in 133 patients (63%) and by a nondiverticular process in 79 (37%). Mortality and morbidity in patients with nondiverticular perforation of the distal large bowel its relationship with the general conditions, the grade and the cause of peritonitis were analysed. Four types of surgical procedures were used. Hartmann's procedure was performed in 40 patients (51%); intraoperative colonic lavage, resection, and primary anastomosis (ICL) in 27 patients (34%); colostomy in 7 (9%); and subtotal colectomy in 5 (6%).Results: Perforated neoplasm, the most common cause of peritonitis, was observed in 30 patients, colonic ischemia in 20, iatrogenia in 13, and other causes in 16 patients. One or more complications were observed in 57 patients (72%); among causes of perforation, colonic ischemia was significantly associated with the longest hospital stay and highest mortality. Eighteen patients (23%) died.Conclusions: Left large bowel perforation by nondiverticular disease is associated with high mortality and morbidity. The prognosis of patients is determined by the development of septic shock and colonic ischemia, as underlying disease, may influence patient survival. (C) 2002 Excerpta Medica, Inc. All rights reserved.

PRESERVATION INJURY is a major contributor to primary allograft dysfunction and failure after liver transplantation. Several studies have shown that cold ischemia (CI) can damage the sinusoidal liver cells. During this process many inflamatory mediators are released locally and to the blood stream. The damaged endothelial cells produce the activation and adhesion of leukocytes. Finally, the infiltration of polymorphonuclear cells increases the cold ischemic lesion. Platelet-activating factor (PAF) is an inflammatory mediator produced by many cell types. It has been implicated in the microcirculatory failure after cold and warm ischemia. PAF antagonist BN-52021 is a natural compound extracted from ginkgo-biloba tree. Its beneficial effect has been reported in ischemia reperfusion injury of many organs. The objective of our study was to demonstrate that the PAF antagonist BN-52021 can attenuate the preservation injury. The isolated perfused rat liver model was employed for reperfusion evaluation.

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.

In this section we will feature outstanding photographs of clinical materials. These will be selected for their educational value, message, or possibly rarity. The images will be accompanied by brief case reports (limit 2 typed pages, 3 references). Our readers are invited to submit items for consideration. In this section we will feature outstanding photographs of clinical materials. These will be selected for their educational value, message, or possibly rarity. The images will be accompanied by brief case reports (limit 2 typed pages, 3 references). Our readers are invited to submit items for consideration. A 70-year-old man underwent a pancreatoduodenectomy for carcinoma of the distal common bile duct. A needle catheter jejunostomy was inserted as an adjunctive procedure, and enteral feeding was begun on the first postoperative day. On the seventh postoperative day, the patient had crampy abdominal pain, progressive distension, and tenderness with metabolic acidosis and leukocytosis. During an emergency laparotomy, intestinal full thickness necrosis was found involving the small bowel beginning at the jejunostomy tube insertion site and continuing for approximately 50 cm distally. There was no evidence of intestinal strangulation or mesenteric arterial occlusion. The necrotic bowel was resected and the pathologic specimen showed transmural necrosis and enteral nutrition impacted in the lumen (Figure).He died shortly after surgery. Recent literature has addressed some of the ischemic complications associated with feeding jejunostomy. The cause of this problem is unclear, but there are many similarities between it and necrotizing enterocolitis, in which there have been many factors implicated, including systemic and luminal features.1Schunn CDG Daly JM Small bowel necrosis associated with postoperative jejunal tube feeding.J Am Coll Surg. 1995; 180: 410-416PubMed Google Scholar Hyperosmolarity of feedings, invasive bacteria, or toxic products from bacterial overgrowth have been implicated as causes for direct mucosal injury and probably as causes of intense local vasospasm and resulting ischemic necrosis.2Smith-Choban P Martin M. Feeding jejunostomy: a small bowel stress test?.Am J Surg. 1988; 155: 112-117Abstract Full Text PDF PubMed Scopus (106) Google Scholar Hyperosmolar enteral diets expose the intestinal mucosa to unphysiologic osmolar loads that may be compensated by normal propulsive peristalsis. In the setting of disordered peristalsis (eg, ileus in the immediate postoperative period) this hyperosmolar load may cause rapid fluid shifts into the bowel lumen with resulting bowel distension, capillary slugging, and decreased perfusion. In our patient, there was evidence of a bolus of impacted enteral nutrition into the jejunal lumen that was probably the pathogenic mechanism for intestinal necrosis.

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.

In pig to human discordant xenotransplantation there is evidence that hyperacute rejection (HAR) is mediated by the binding of natural xenoantibodies (NxAb) to endothelial xenoantigens with subsequent complement system activation.1 Hence, prolonged graft survival using complement inhibitors such as cobra venom factor,2 sCR1,3 or transgenic animals expressing human complement regulatory proteins such as DAF4 or CD59,5 has been observed. Thus, complement plays a pivotal role in endothelial barrier disruption and in the development of HAR.6

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.

BACKGROUND:The surgical management of left colonic emergencies has evolved in the past few decades. Recently, there has been increasing interest in resection with primary anastomosis in selected cases. The aim of this study was to evaluate the differences in outcome in patients with peritonitis or obstruction treated by resection, on-table lavage and primary anastomosis of the left colon.METHODS:Between January 1992 and August 1995, 212 patients underwent emergency operation for a distal colonic lesion: 97 presented with peritonitis, 113 with obstruction and two with other indications. Intraoperative colonic lavage was performed in 37 patients with obstruction and in 24 with an acute intra-abdominal inflammatory process.RESULTS:The postoperative mortality rate was 5 per cent. The incidence of clinical anastomotic leakage was 5 per cent. Wound infection was observed in ten patients (16 per cent), more often in those with peritonitis (P = 0.03). The overall mean(s.d.) hospital stay was 15(9) days.CONCLUSION:Resection, on-table lavage and primary anastomosis constitute the operation of choice for selected patients with left colonic emergency.

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.

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.