Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis

AIM: To study the safety of epidural anesthesia(EA),its effect on pancreatic perfusion and the outcome of patients with acute pancreatitis(AP).METHODS: From 2005 to August 2010,patients with predicted severe AP [Ranson score ≥ 2,C-reactive protein > 100 or necrosis on computed tomography(CT)] were prospectively randomized to either a group receiving EA or a control group treated by patientcontrolled intravenous analgesia. Pain management was evaluated in the two groups every eight hours using the visual analog pain scale(VAS). Parameters for clinical severity such as length of hospital stay,use of antibiotics,admission to the intensive care unit,radiological/clinical complications and the need for surgical necrosectomy including biochemical data were recorded. A CT scan using a perfusion protocol was performed on admission and at 72 h to evaluate pancreatic blood flow. A significant variation in blood flow was defined as a 20% difference in pancreatic perfusion between admission and 72 h and was measured in the head,body and tail of the pancreas.RESULTS: We enrolled 35 patients. Thirteen were randomized to the EA group and 22 to the control group. There were no differences in demographic characteristics between the two groups. The Balthazar radiological severity score on admission was higher in the EA group than in the control group(mean score 4.15 ± 2.54 vs 3.38 ± 1.75,respectively,P = 0.347) and the median Ranson scores were 3.4 and 2.7 respectively(P = NS). The median duration of EA was 5.7 d,and no complications of the epidural procedure were reported. An improvement in perfusion of the pancreas was observed in 13/30(43%) of measurements in the EA group vs 2/27(7%) in the control group(P = 0.0025). Necrosectomy was performed in 1/13 patients in the EA group vs 4/22 patients in the control group(P = 0.63). The VAS improved during the first ten days in the EA group compared to the control group(0.2 vs 2.33,P = 0.034 at 10 d). Length of stay and mortality were not statistically different between the 2 groups(26 d vs 30 d,P = 0.65,and 0% for both respectively).CONCLUSION: Our study demonstrates that EA increases arterial perfusion of the pancreas and improves the clinical outcome of patients with AP.

Vascular invasion in pancreatic cancer:Imaging modalities,preoperative diagnosis and surgical management

Pancreatic cancer is associated with a poor prognosis,and surgical resection remains the only chance for curative therapy.In the absence of metastatic disease,which would preclude resection,assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer.A frequent error is to misdiagnose an involved major vessel.Obviously,surgical exploration with pathological examination remains the"gold standard"in terms of evaluation of resectability,especially from the point of view of vascular involvement.However,current imaging modalities have improved and allow detection of vascular invasion with more accuracy.A venous resection in pancreatic cancer is a feasible technique and relatively reliable.Nevertheless,a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion.Although the discovery of an arterial invasion during the operation might require an aggressive management,discovery before the operation should be considered as a contraindication.Detection of vascular invasion remains one of the most important challenges in pancreatic surgery.The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.

Neutrophil depletion-but not prevention of Kupffer cell activation-decreases the severity of cerulein-induced acute pancreatitis

瞄准：为了决定嗜中性的弄空和 Kupffer 房间抑制是否可能联合，他们的 protective 完成尖锐胰腺炎的严厉到减少。方法：老鼠有 cerulein 管理导致尖锐胰腺炎并且是有任何一个反老鼠 neutrophil 浆液或金轧氯化物(GdCl3 ) 的 pretreated 阻止 Kupffer 房间激活，或两个处理。损害在胰和肺被估计。Myeloperoxidases (军邮局) 估计了嗜中性的渗入。Interleukin-6 (IL-6 ) 和 IL-10 在浆液，胰，肺和肝被测量。结果：在有尖锐胰腺炎的老鼠，嗜中性的弄空减少了胰腺炎和联系胰腺炎的肺损害的严厉。在由 GdCl3 的激活的 Kupffer 房间有更少的保护的效果，尽管 IL-6 和 IL-10 集中显著地被减少。嗜中性的弄空带的普雷茨氏疗法没被 Kupffer 房间在激活提高，两个处理没联合他们的保护的效果。结论：当 Kupffer 房间激活的角色是不太明显的时，我们的结果在在尖锐胰腺炎加重机关损害证实激活的 neutrophils 的角色。

Segmental duodenectomy for gastrointestinal stromal tumor of the duodenum

AIM: To evaluate the results of segmental duodenectomy (SD) and pancreaticoduodenectomy (PD) for duodenal gastrointestinal stromal tumor (GIST) and help clinicians with surgical management. METHODS: All patients who underwent surgery for non-metastatic GIST of the duodenum in a single institution since 2000 were prospectively followed up. Seven patients (median age 51 years, range: 41-73 years) were enrolled: five underwent SD and two underwent PD. RESULTS: All the patients had a complete resection (R0), with no postoperative morbidity and mortality. Among the SD group, GIST was classified as low risk in two patients, intermediate risk in two, and high risk in one, according to the Fletcher scale, (vs two high risk patients in the PD group). With a median followup of 41 (18-85) mo, disease-free survival (DFS) rateswere 100% after SD and 0% after PD (P < 0.05). The median DFS was 13 mo in the PD group. CONCLUSION: Whenever associated with clear surgical margins, SD is a reliable and curative option for most duodenal GISTs, and is compatible with longterm DFS.

Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer:A review

Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds.Such large wounds are prone to infection and perineal herniation,and their closure is a major concern to most surgeons.Different approaches to the perineal repair exist,varying from primary or mesh closure to myocutaneous flaps.Each technique has its own associated advantages and potential complications and the ideal approach is still debated.In the present study,we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure.Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction.In addition,the rate of perineal hernia is lower in early follow-up,while long-term hernia occurrence appears to be similar between the different techniques.Finally,it is an easy and quick reconstruction method.Although more expensive than primary closure,the cost associated with the use of a biological mesh is at least equal,if not less,than flap reconstruction.

Management of hepatocellular adenoma: Solitary-uncomplicated, multiple and ruptured tumors

AIM: While hepatocellular adenomas (Has) have often been studied as a unique entity, we aimed to better define current management of the various forms of Has.METHODS: Twenty-five consecutive patients operated for solitary-uncomplicated (9), multiple (6), and ruptured (10)Has were reviewed according to management strategies and outcomes.RESULTS: All solitary-uncomplicated Has (ranged 2.2-14 cm in size) were removed. Out of 25 Has, 2 (8%) included foci of carcinoma. In the multiple HA group, previously undiagnosed tumors were identified during surgery in 5/6cases. In three cases with multiple spread HA, several lesions had to be left unresected. They remained unmodified after 4-, 6-, and 6-year radiological follow-up. Patients with ruptured HA (ranged 1.7-10 cm in size) were initially managed with hemodynamic support and angiography,allowing the embolization of actively bleeding tumors in two patients. All ruptured tumors were subsequently removed 5.5 d (range 4-70 d) after admission. CONCLUSION: Tumors suspected of HA, regardless of the size, should be resected, because of high chances of rupture causing bleeding, and/or containing malignant foci.Although it is desirable to remove all lesions of multiple HA, this may not be possible in some patients, for whom long-term radiological follow-up is advised. Ruptured HA can be managed by hemodynamic support and angiography,allowing scheduled surgery.

Perforated duodenal diverticulum, a rare complication of a common pathology: A seven-patient case series

Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists' score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.

Soluble CD40 ligand in prediction of acute severe pancreatitis

瞄准：在胰腺炎严厉估计可溶的 CD40L (sCD40L ) 的早可预测性。方法：在 2000 年 2 月和 2003 年 2 月之间，有尖锐胰腺炎的 279 个连续病人有希望地在我们的学习被注册。在这份报告， 40 个病人与温和并且有严重胰腺炎的 40 个病人随机被学习。sCD40L 集中被测量在承认以后的 48 个小时。结果：sCD40L 层次显著地更高在在严重胰腺炎的承认以后的 48 个小时比在温和胰腺炎。用 1000 的截止，检测疾病的一堂严重功课的 sCD40L 的 pg/L，敏感和特性为 CRP 与 72% 和 81% 相比分别地是 78% 和 62% 。发现那 CRP 的逻辑回归分析统计上是唯一的能检测疾病的一堂严重功课的重要标记。结论：这些调查结果显示 CRP 仍然是一个珍贵标记而 sCD40L 层次应该在进一步的研究被估计，决定尖锐胰腺炎的严厉和预后。

Squamous cell carcinoma of the anus-an opportunistic cancer in HIV-positive male homosexuals

Squamous cell carcinoma of the anus (SCCA) is a common cancer in the human immunodeficiency virus (HIV)infected population,and its incidence continues to increase in male homosexuals.Combined chemoradiation with mitomycin C and 5-fluorouracil was poorly tolerated by severely immunocompromised patients in the early 1990s.In the era of highly active antiretroviral therapy (HAART),however,recent data indicate that:(1) most HIV patients with anal cancer can tolerate standard chemotherapy regimens;and (2) this approach is associated with survival rates similar to those of HIV-negative patients.However,HIV-positive patients with SCCA are much younger,more likely to develop local tumor recurrence,and ultimately die from anal cancer than immune competent patients.Taken together,these findings suggest that anal cancer is an often fatal neoplasia in middle-aged HIV-positive male homosexuals.In this population,SCCA is an opportunistic disease resulting in patients with suboptimal immune function from persistent infection and prolonged exposition to oncogenic human papillomaviruses (HPVs).Large-scale cancer-prevention strategies (routine anuscopy and anal papanicolaou testing) should be implemented in this population.In addition,definitive eradication of oncogenic HPVs within the anogenital mucosa of high-risk individuals might require a proactive approach with repeated vaccination.

Endothelial nitric oxide synthase regulation is altered in pancreas from cirrhotic rats

瞄准：决定胆汁性肝硬变是否能在内皮的氮的氧化物 synthase (eNOS ) 导致象修正那样的胰腺的机能障碍表达式并且 eNOS 的规定是否能被规章的蛋白质 caveolin 改变并且加热吃惊蛋白质 90 (Hsp90 ) ，以及由对 eNOS 有约束力的 calmodulin 的修正。方法：Immunoprecipitations 和西方的弄污分析在从假冒、肝脏硬化症的老鼠孤立的胰被执行。结果：胰腺的损害在肝脏硬化症的老鼠是次要的，但是 eNOS 表示重要地与长度减少了(并且严厉) 疾病。因为有 Hsp90 和 caveolin 的 eNOS 的 co-immunoprecipitation 同样在肝脏硬化症的老鼠减少了， eNOS 活动没被这机制修改。相反，肝硬化减少了 calmodulin 绑定到有在 eNOS 的伴随物减少的 eNOS 活动。结论：在胆汁性肝硬变，胰腺的损害是次要的但是胰腺的氮的氧化物(没有) 生产被二机制显著地减少：酶和到 eNOS 的 calmodulin 的减少的绑定的减少的表情。

Natural history of uncomplicated sigmoid diverticulitis

While diverticular disease is extremely common, the natural history(NH) of its most frequent presentation(i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to populationbased or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein > 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon > 5 cm. The risk of developing a complicated second episode(and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.

Islet transplantation in multicenter networks:the GRAGIL example

Purpose of review The enthusiasm generated by the results of the Edmonton protocol of islet transplantation is inciting a great number of institutions to start such programs.However,the procedure of islet isolation and purification is costly,complex and technically challenging.In order to share costs and to avoid facing the steep learning curve of the procedure,many centers interested in islet transplantation have looked into collaborating with experienced groups serving as core islet isolation facilities.Recent findings The proof of principle that remote islet processing and shipment could be successfully implemented with obtainng the Portland/Minneapolis,Huddinge/Giessen and Houston/Miami partnerships.Moreover,in order to increase both the donor pool and the number of patients gaining access to islet transplantation,multicenter networks,such as the Swiss-French GRAGIL consortium and the 4-country Nordic Network in Scandinavia have been built.The GRAGIL group has been fully operational since 1999,allowing the transplantation of 27 islet preparations processed in Geneva,Switzerland into 20 recipients in France over the course of 4.5 years.Organizational issues in the design of such networks are discussed based on the example of the GRAGIL experience.Summary The feasibility and the efficiency of islet transplantation in multicenter networks have been demonstrated.This strategy allows to increase the donor pool and the accessibility to islet transplantation in an extended population area.(J Intervent Radiol,2006,15: 626-631)