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.

A body-packer with a cocaine bag stuck in the stomach

Management of patients carrying packets of drugs in the digestive tract is a frequent medical problem.Wereport on a patient who was referred by the police after ingestion of packets of cocaine.After spontaneous elimination of 81 drug packets,the patient had three unremarkable stools.A plain abdominal X-ray disclosed no residual packet but computed tomography(CT) scan showed one in the stomach.As this was not eliminated during the 10 d following ingestion,it was removed through gastrotomy.This case stresses the usefulness of the CT scan to ensure that no residual packet is present before hospital discharge.