Management of infected acute necrotizing pancreatitis

Necrotizing or severe pancreatitis represents approximately 10%-20%of acute pancreatitis.30%-40%of patients with acute necrotizing pancreatitis(ANP)will develop debris infection through translocation of intestinal microbial flora.Infected ANP constitutes a serious clinical condition and is complicated by severe sepsis with high mortality rates of up to 40%despite progress in current intensive care.The timely detection of sepsis is crucial.The Quick Sequential Organ Failure Assessment score,procalcitonin levels>1.8 ng/mL and increased lactates>2 mmol/L(>18 mg/dL),indicate the need for urgent management.The escalated step-by-step management protocol starts with broad-spectrum antibiotics,percutaneous drainage or endoscopic management,and ends with surgical management if needed.The latter includes necrosectomy(either laparoscopic or traditional open surgery),peritoneal lavage and extensive drainage.This management protocol increases the chance of survival to approximately 60%in patients with otherwise fatal cases.Any treatment choice must be individualized,and the timing is critical.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism(pHPT)is the third most common endocrine disease.The surgical procedure aims for permanent cure,but recurrence has been reported in 4%-10%of pHPT patients.Preoperative localization imaging is highly valuable.It includes ultrasound,computed tomography(CT),single-photonemission CT,sestamibi scintigraphy and magnetic resonance imaging.The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months.Ongoing hypercalcemia during this period is defined as persistence,and recurrence is defined as hypercalcemia after six months of normocalcemia.Vitamin D is a crucial factor for a good outcome.Intraoperative parathyroid hormone(PTH)monitoring can safely predict the outcomes and should be suggested.PTH≤40 pg/mL or the traditional decrease≥50%from baseline minimizes the likelihood of persistence.Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology.Risk factors for recurrence are cardiac history,obesity,endoscopic approach and low-volume center(at least 31 cases/year).Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/recurrence.A 6-mo calcium>9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up.18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation.With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement,the recurrence rate has dropped to 2.5%-5%.Sixmonth serum calcium≥9.8 mg/dL and parathyroid hormone≥80 pg/mL indicate a risk of recurrence.Negative sestamibi scintigraphy,diabetes and elevated osteocalcin levels are predictors of multiglandular disease,which brings an increased risk of persistence and recurrence.Bilateral neck exploration was considered the gold-standard diagnostic method.Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques.Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence.Long-term follow-up,even up to 10 years,is necessary.

Use of isolated Roux loop for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy

AIM: To evaluate the efficacy of the isolated Roux loop technique in decreasing the frequency of pancreaticojejunal anastomosis failure. METHODS: We retrospectively reviewed 88 consecutive patients who underwent pancreaticoduodenectomy (standard or pylorus-preserving). Single jejunal loop was used in 42 patients (SL group) while isolated Roux loop was used in 46 patients (RL group). Demographic characteristics (age, gender) and perioperative results (major/minor complications, mortality, hospital stay) were compared between the two groups. RESULTS: Mortality was almost equal in both groups and overall mortality was 2.27%. Leak rate from the pancreaticojejunal anastomosis and hospital stay were lower in the RL group without significant difference. Morbidity was 39.1% in the RL group, insignificantly higherthan the SL group. Operative time was almost 30 min longer in the RL group. CONCLUSION: The isolated Roux loop, although an equally safe alternative, does not present advantages over the traditional use of a single jejunal loop. Randomized controlled studies are required to further clarify its efficacy.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver,with five-year survival rates up to 58% in selected cases.However,only a minority are resectable at the time of diagnosis.Continuous research in this field aims at increasing the percentage of patients eligible for resection,refining the indications and contraindications for surgery,and improving overall survival.The use of surgical innovations,such as staged resection,portal vein embolization,and repeat resection has allowed higher resection rates in patients with bilobar disease.The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection.Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates.Current management of colorectal liver metastases requires a multidisciplinary approach,which should be individualized in each case.

Barrett's esophagus with high-grade dysplasia:Focus on current treatment options

High-grade dysplasia(HGD) in Barrett's esophagus(BE) is the critical step before invasive esophageal adenocarcinoma.Although its natural history remains unclear,an aggressive therapeutic approach is usually indicated.Esophagectomy represents the only treatment able to reliably eradicate the neoplastic epithelium.In healthy patients with reasonable life expectancy,vagal-sparing esophagectomy,with associated low mortality and low early and late postoperative morbidity,is considered the treatment of choice for BE with HGD.Patients unfit for surgery should be managed in a less aggressive manner,using endoscopic ablation or endoscopic mucosal resection of the entire BE segment,followed by lifelong surveillance.Patients eligible for surgery who present with a long BE segment,multifocal dysplastic lesions,severe reflux symptoms,a large fixed hiatal hernia or dysphagia comprise a challenging group with regard to the appropriate treatment,either surgical or endoscopic.