Management of necrotizing pancreatitis

Infection complicating pancreatic necrosis leads to persisting sepsis, multiple organ dysfunction syndrome and accounts for about half the deaths that occur following acute pancreatitis. Severe cases due to gallstones require urgent endoscopic sphincterotomy. Patients with pancreatic necrosis should be followed with serial contrast enhanced computed tomography (CE-CT) and if infection is suspected fine needle aspiration of the necrotic area for bacteriology (FNAB) should be undertaken. Treatment of sterile necrosis should initially be non-operative. In the presence of infection necrosectomy is indicated. Although traditionally this has been by open surgery, minimally invasive procedures are a promising new alternative. There are many unresolved issues in the management of pancreatic necrosis. These include, the use of antibiotic prophylaxis, the precise indications for and frequency of repeat CE-CT and FNAB,and the role of enteral feeding.

Surgery for pancreatic necrosis:“Whom, when and what”

Acute pancreatitis is a common condition in which 70% of patients will recover with simple medical management. For patients who develop extensive or infected pancreatic necrosis the outcome is significantly different with a high morbidity and mortality. Surgery is the mainstay of treatment for these patients but several unresolved issues remain including who requires surgery, when is the optimal time to intervene and what technique should be used.

Systemic meta-analysis assessing the short term applicability of early conversion to mammalian target of rapamycin inhibitors in kidney transplant

AIM To consolidate the present evidence of effectiveness in renal functioning and graft survival following early introduction of mammalian target of rapamycin(m TOR) inhibitors with or without calcineurin inhibitors(CNIs) in renal transplant recipients.METHODS We analysed the current literature following PROSPERO approval describing the role of immunosuppressive agent, m TOR inhibitors as an alternative to CNI within six months of renal transplant by searching the Pub Med, EMBASE, Cochrane, Crossref, and Scopus using Me SH terms. RESULTS Six articles of early withdrawal of CNI and introduction of m TOR-inhibitors within six months of renal transplantation were sought. Glomerular filtration rate(GFR) and serum creatinine were significantly better in m TOR inhibitor group with equivalent survival at 12 mo, even though Biopsy Proven Acute rejection was significantly higher in m TOR-inhibitor group. CONCLUSION The evidence reviewed in this meta-analysis suggests that early introduction m TOR-inhibitors substantial CNI minimization. The m TOR inhibitors such as everolimus and sirolimus, due to their complementary mechanism of action and favourable nephrotoxicity profile; better glomerular filtration, lower serum creatinine with equivalent survival. Having said that, due to the higher rejection rate, may influence the use of these regimens to patients with moderate to high immunological risk patients.

Clinico-pathological aspects of colorectal serrated adenomas

AIM： To study the association of colorectal serrated adenomas （SAs） with invasive carcinoma, local recurrence, synchronicity and metachronicity of lesions. METHODS： A total of 4536 polyps from 1096 patients over an eight-year period （1987-1995） were retrospectively examined. Adenomas showing at least 50% of serrated architecture were called SAs by three reviewing pathologists. RESULTS： Ninety-one （2%） of all polyps were called SAs, which were found in 46 patients. Invasive carcinomas were seen in 3 out of 46 （6.4%） patients, of whom one was a case of familial adenomatous polyposis （FAP）. A male preponderance was noted and features of a mild degree of dysplasia were seen in majority （n=75, 83%） of serrated adenomas. Follow-up ranged 1-12 years with a mean time of 5.75 years. Recurrences of SAs were seen in 3 （6.4%） cases, synchronous SAs in 16 （34.8%） cases and metachronous SAs in 9 （19.6%） cases. CONCLUSION： Invasive carcinoma arising in serrated adenoma is rare, accounting for 2 （4.3%） cases studied in this series.