Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A national survey and case-vignette study

BACKGROUND Splanchnic vein thrombosis(SVT)is a major complication of moderate and severe acute pancreatitis.There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.AIM To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.METHODS A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey.The threshold to assume group agreement was set at 75%.RESULTS The response rate was 67%(n=93).Seventy-one pancreatologists(77%)regularly prescribed therapeutic anticoagulation in case of SVT,and 12 pancreatologists(13%)for narrowing of splanchnic vein lumen.The most common reason to treat SVT was to avoid complications(87%).Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation(90%).Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation(76%)and splenic vein thrombosis as the least preferred location(86%).The preferred initial agent was low molecular weight heparin(LMWH;87%).In the case vignettes,therapeutic anticoagulation was prescribed for acute portal vein thrombosis,with or without suspected infected necrosis(82%and 90%),and thrombus progression(88%).Agreement was lacking regarding the selection and duration of long-term anticoagulation,the indication for thrombophilia testing and upper endoscopy,and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.CONCLUSION In this national survey,the pancreatologists seemed to agree on the use of therapeutic anticoagulation,using LMWH in the acute phase,for acute portal thrombosis and in the case of thrombus progression,irrespective of the presence of infected necrosis.

Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy

AIM To study the effect of different techniques of cystic duct closure on bile leakage after laparoscopic cholecystectomy(LC) for biliary disease.METHODS A systematic search of MEDLINE, Cochrane and EMBASE was performed. Rate of cystic duct leakage(CDL) was the primary outcome. Risk of bias was evaluated. Odds ratios were analyzed for comparison of techniques and pooled event rates for non-comparative analyses. Pooled event rates were compared for each of included techniques.RESULTS Out of 1491 articles, 38 studies were included. A total of 47491 patients were included, of which 38683(81.5%)underwent cystic duct closure with non-locking(metal)clips. All studies were of low-moderate methodological quality. Only two studies reported separate data on uncomplicated and complicated gallbladder disease. For overall CDL, an odds ratio of 0.4(95%CI: 0.06-2.48)was found for harmonic energy vs clip closure and an odds ratio of 0.17(95%CI: 0.03-0.93) for locking vs non-locking clips. Pooled CDL rate was around 1% for harmonic energy and metal clips, and 0% for locking clips and ligatures. CONCLUSION Based on available evidence it is not possible to either recommend or discourage any of the techniques for cystic duct closure during LC with respects to CDL,although data point out a slight preference for locking clips and ligatures vs other techniques. No separate recommendation can be made for complicated gallbladder disease.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy:A retrospective analysis of a prospective cohort

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Nurses Opinions Regarding Delirium Care in the Older General Hospital Population and in Older Cardiac Surgery Patients Specifically: A Multicentre Survey among Dutch Nurses

Background: Delirium is a high prevalent postoperative complication in older cardiac surgery patients and can have drastic consequence for the patient. Preventive interventions, diagnosis and treatment of delirium require specialized knowledge and skills. Objective: To gain insight in the current opinion and beliefs of nurses in hospitals concerning prevention, diagnosis and treatment of delirium in older hospital patients in general and specifically in older cardiac surgery patients. Methods: In a cross-sectional study from February to July 2010, we distributed a survey on beliefs on delirium care among 368 nurses in three hospitals in the Netherlands, in one hospital in all wards with older patients and in two hospitals in the cardiac surgery wards only. Results: Although in literature incidence rates up to 54.9% in cardiac surgery patients in hospitals are reported, with a response rate of 68% (250), half of the nurses believe that the incidence of delirium is not even 10%. Two thirds think that delirium in patients is preventable. Although, the Delirium Observation Scale is most often used for screening delirium, nearly all nurses do not routinely screen patients for delirium. Opinions on delirium of nurses working in cardiac surgery wards did not differ from nurses caring for older patients in other hospital wards. Conclusions: Nurses do have knowledge on delirium care, but there is a gap between the reported incidence in literature and the estimation of the occurrence of delirium by nurses. A two-way causal relationship emerges: because nurses underestimate the occurrence, they do not screen patients on a routine basis. And because they do not screen patients on a routine basis they underestimate the incidence.

Non-invasive Angiographic-based Fractional Flow Reserve:Technical Development,Clinical Implications,and Future Perspectives

New non-and less-invasive techniques have been developed to overcome the procedural and operator related burden of the fractional flow reserve(FFR)for the assessment of potentially significant stenosis in the coronary arteries.Virtual FFR-techniques can obviate the need for the additional flow or pressure wires as used for FFR measurements.This review provides an overview of the developments and validation of the virtual FFR-algorithms,states the challenges,discusses the upcoming clinical trials,and postulates the future role of virtual FFR in the clinical practice.

Pulmonary hypertension in hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia(HHT) is an autosomal dominant inherited disorder characterised by vascular malformations in predominantly the brain,liverand lungs.Pulmonary hypertension(PH) is increasingly recognised as a severe complication of HHT.PH may be categorised into two distinct types in patients with HHT.Post-capillary PH most often results from a high pulmonary blood flow that accompanies the high cardiac output state associated with liver arteriovenous malformations.Less frequently,the HHT-related gene mutations in ENG or ACVRL1 appear to predispose patients with HHT to develop pre-capillary pulmonary arterial hypertension.Differentiation between both forms of PH by right heart catheterisation is essential,since both entities are associated with severe morbidity and mortality with different treatment options.Therefore all HHT patients should be referred to an HHT centre.

Pancreatitis and pancreatic cancer:A case of the chicken or the egg

Acute pancreatitis(AP),chronic pancreatitis(CP)and pancreatic cancer are three distinct pancreatic diseases with different prognoses and treatment options.However,it may be difficult to differentiate between benign and malignant disease.AP may be a first symptom of pancreatic cancer,particularly in patients between the ages of 56 and 75 with presumed idiopathic AP who had a concomitant diagnosis of new-onset diabetes mellitus or patients who present with CP at diagnosis of AP.In these patients,additional imaging is warranted,preferably by endoscopic ultrasonography.CP may lead to pancreatic cancer through oncogenic mutations,mostly in patients with hereditary CP,and in patients in whom risk factors for pancreatic cancer(e.g.,nicotine and alcohol abuse)are also present.Patients with PRSS1-mediated CP and patients with a history of autosomal dominant hereditary CP without known genetic mutations may be considered for surveillance for pancreatic cancer.Pancreatic inflammation may mimic pancreatic cancer by appearing as a focal mass-forming lesion on imaging.Differentiation between the above mentioned benign and malignant disease may be facilitated by specific features like the duct-penetrating sign and the duct-to-parenchyma ratio.Research efforts are aimed towards developing a superior discriminant between pancreatitis and pancreatic cancer in the form of imaging modalities or biomarkers.This may aid clinicians in timely diagnosing pancreatic cancer in a potentially curable stage.

Percutaneous closure of secundum type atrial septal defects:More than 5-year follow-up

AIM: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect(ASD) closure in adults.METHODS: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic moni toring. Transthoracic echocardiography(TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt(RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt(LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients' characteristics. Univariate analysis was used to identify predictors for residual shunting.RESULTS: In total, 104 patients(mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device(ASO) in 76 patients and a Cardioseal/Starflex device(CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization(1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up(2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia's occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4%(minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5%(minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.CONCLUSION: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.

Evaluation of Cladribine treatment in refractory celiac disease type Ⅱ

AIM: To evaluate cladribine [2-chlorodeoxyadenosine (2-CdA)] therapy in refractory celiac disease (RCD) Ⅱ. METHODS: An open-label cohort-study of RCD Ⅱ patients treated with 2-CdA was performed between 2000 and 2010. Survival rate, enteropathy associated T-cell lymphoma (EATL) occurrence, clinical course, and histological and immunological response rates were evaluated. RESULTS: Overall, 32 patients were included with a median follow-up of 31 mo. Eighteen patients responded well to 2-CdA. Patients responsive to 2-CdA had a statistically significant increased survival compared to those who were unresponsive. The overall 3- and 5-year survival was 83% in the responder and 63% and 22% in the non-responder group, respectively. The overall 2-year clinical, histological and immunological response rates were 81%, 47% and 41%, respectively. Progression into EATL was reported in 16%, all of these patients died. CONCLUSION: Treatment of RCD Ⅱ with 2-CdA holds promise, showing excellent clinical and histological response rates, and probably less frequent transition into EATL.

感知胃灼热和反胃的决定因素

Background and aim: It is not known why some reflux episodes evoke symptoms and others do not. We investigated the determinants of perception of gastro-oesophageal reflux. Methods: In 32 patients with symptoms suggestive of gastro-oesophageal reflux, 24 hour ambulatory pH and impedance monitoring was performed after cessation of acid suppressive therapy. In the 20 patients who had at least one symptomatic reflux episode, characteristics of symptomatic and asymptomatic reflux episodes were compared. Results: A total of 1807 reflux episodes were detected, 203 of which were symptomatic. Compared with asymptomatic episodes, symptomatic episodes were associated with a larger pH drop (p < 0.001), lower nadir pH (p < 0.05), and higher proximal extent (p < 0.005). Symptomatic reflux episodes had a longer volume and acid clearance time (p < 0.05 and p < 0.002). Symptomatic episodes were preceded by a higher oesophageal cumulative acid exposure time (p < 0.05). The proximal extent of episodes preceding regurgitation was larger than those preceding heartburn; 14.8% of the symptomatic reflux episodes were weakly acidic. In total, 426 pure gas reflux episodes occurred, of which 12 were symptomatic. Symptomatic pure gas reflux was more frequently accompanied by a pH drop than asymptomatic gas reflux (p < 0.05). Conclusions: Heartburn and regurgitation are more likely to be evoked when the pH drop is large, proximal extent of the refluxate is high, and volume and acid clearance is delayed. Sensitisation of the oesophagus occurs by preceding acid exposure. Weakly acidic reflux is responsible for only a minority of symptoms in patients off therapy. Pure gas reflux associated with a pH drop (“ acid vapour” ) can be perceived as heartburn and regurgitation.

应用视频胶囊内镜检查可疑小肠病变的结果

We aimed to assess technical feasibility,clinical applicability,and diagnostic yield of videocapsule endoscopy(VCE) in a large group of unselected patients.VCE was performed with the Given Imaging swallowable capsule.Findings were considered diagnostic if the observed finding could explain the symptomatology of the patient.Findings were considered suspicious if an observed finding failed to completely explain the patient’s symptoms.We studied 250 patients.A definite diagnosis was made in 95 patients(38%) .Suspicious findings were noted in 80 patients(32%) .No diagnosis was obtained in 74 patients(30%) .The yield of VCE was higher in patients with suspected Crohn’s disease.Mean viewing time decreased significantly from 51 ± 14 to 30 ± 7 minutes after reviewing 50 procedures.VCE is an important diagnostic tool,but a definite diagnosis is established in only 38% of the patients.The highest diagnostic yield is obtained in patients with suspected Crohn’s disease.

膈肌和食管下括约肌的间歇性空间分离促进酸性和轻度酸性反流

Background & Aims: In small hiatal hernias, the size of the hernia is variable. Intermittent complete reduction can be observed with high-resolution manometry as a transition from a doublepeak (hernia) to a single-peak (reduced) high-pressure zone. The aim of this study was to investigate whether intermittent separation of the diaphragm and lower esophageal sphincter (LES) favors the occurrence of gastroesophageal reflux. Methods: In 16 patients with a small hiatal hernia (3 cm), prolonged high-resolution manometry was performed. Acid and weakly acidic reflux episodes were detected with pH-impedance monitoring. Results: The single pressure peak profile (reduced hernia) was present for 814 minutes (56.5% of total time), and the double peak profile (unreduced hernia) was present for 626 minutes (43.5% of total time). In all patients, both pressure profiles were observed. The transition rate between the 2 profiles was 7.5 ± 0.9 per hour. More reflux occurred when the LES and diaphragm were separated versus the reduced hernia state (23.1 ± 5.1 vs 12.2 ± 2.4 episodes per hour, respectively; P < .05). The proportions of acidic reflux episodes during the single and double pressure peaks were similar (70% and 67% , respectively). In the two-pressure-zone state, there was an increase in all reflux mechanisms except transient LES relaxation. Conclusions: In patients with a small hiatal hernia, intermittent reduction of the hernia occurs frequently. Spatial separation of the diaphragm and LES in the nonreduced state results in a 2- fold increase in acidic and weakly acidic reflux due to mechanisms other than transient LES relaxation.

超声下双侧输卵管成功放置Essure微栓子的随访

To evaluate the reliability of pelvic X- ray and transvaginal ultrasound to localize Essure microinserts (Conceptus,San Carlos, California) after successful place-ment in both fallopian tubes 3 months after placement. Design: Prospective,observational study. Setting: Gynecology departments at two teaching hospitals. Patient(s): One hundred eighty- two patients who underwent hysteroscopic sterilization by placement of Essure microinserts between August 2002 and August 2004. Intervention(s): Transvaginal ultrasound, pelvic X- ray,and hysterosalpingography (HSG) 3 months after sterilizationwith Essure. Main Outcome Measure(s): Transvaginal ultrasound confirmation of correct localization of microinserts after a 3- month follow- up. Result(s): In 150 of 182 patients, confirmation of successful bilateral placement of two microinserts(300 devices) was possible. In 9 patients it was not possible to identify both devices with ultrasound, or there was doubt about the extension of the device through the uterotubal junction. The other 291 devices were identified as being in a good position.Conclusion(s): Hysterosalpingography at the 3- month follow-up after successful placement of Essure microinserts can be replaced by transvaginal ultrasonography. A 3- month follow-up with HSG after the Essure procedure is only required after unsatisfactory placements. In those patients in whom transvaginal ultrasonography can not confirm satisfactory localization, acomplementary pelvic X- ray should be performed.

利用腔内电阻抗检测研究吞气症:胃源性及胃上性嗳气

Background: Patients with aerophagia are believed to have excessive belches due to air swallowing. Intraluminal impedance monitoring has made it possible to investigate the validity of this concept. Methods: The authors measured oesophageal pH and electrical impedance before and after a meal in 14 patients with exces sive belching and 14 healthy controls and identified patterns of air transport through the oesophagus. The size of the gastric air bubble was measured radiograp hically. In four patients prolonged oesophageal manometry was performed simultan eously. Results: In all subjects, impedance tracings showed that a significant a mount of air is propulsed in front of about a third of the swallow induced peris taltic waves. Two types of retrograde gas flow through the oesophagus (belch) were observed. In the first type air flowed from the stomach through the oesophagus in oral direction (“gastric belch”). In the second type air entered the oesophagus rapidly from proximal and was expulsed almost immediately in oral directi on (“supragastric belch”). The incidence of air-containing swallows and gastric belches was similar in patients and controls but supragastric belches occurred exclusively in patients. There was no evidence of lower oesophageal sphincter relaxation during supragastric belches. Gastric air bubble sizewas not different between the two groups. Conclusions: In patients with excessive belching the in cidence of gaseous reflux from stomach to oesophagus is similar to that in healthy subjects. Their excess belching activity follows a distinct pattern, characte rised by rapid antegrade and retrograde flow of air in the oesophagus that does not reach the stomach.

早孕失败妇女首选米索前列醇

The aim of this study was to assess the preference of women with early pregnancy failure for treatment with misoprostol as compared to curettage. Study design: Women with early pregnancy failure were interviewed and asked whether they were motivated to trade a non-invasive but potentially less effective treatment with misoprostol at the virtually 100% guarantee of complete evacuation after curettage. All women had a structured interview, in which they were informed about both treatment options. The women were asked for a treatment preference in case the complete evacuation rate after misoprostol was set at 100% . In case the women preferred misoprostol, the complete evacuation rate was subsequently decreased to 10% using steps of 5% . Results: The study group consisted of 64 women with early pregnancy failure. Seven women (11% )- did not opt for misoprostol at all, because of fear of pain or bleeding using misoprostol. Fifty percent of the women would prefer misoprostol if its complete evacuation rate exceeds 65% . Conclusion: A majority of women would prefer misoprostol over curettage if its complete evacuation rate exceeds 65% .

如何在肱动脉水平正确地测量平均压?

目的:传统的上肢平均动脉压计算是以1/3脉压加舒张压。作者对该公式的普通适用性提出质疑。方法:使用57例受试者先前记录的静息肱动脉内压和Riva-Rocci Korotkoff血压(研究A)以及22例非卧床受试者的24h动脉内压记录(研究B)进行评估。结果:研究A中,所有受试者动脉内测量的"真正"平均压为舒张压加上39.5%±2.5%的脉压,即水平高于预期的33.3%脉压。该结果与年龄、血压、脉压或心率均无关。因此,当根据动脉内压读数计算时,采用传统的1/3法计算的平均压低估了"真正"平均压5.0±2.3mm H g(P【

“One-day,one-stay,and one-step”lessons from the Danish guidelines for the treatment of gallstone disease

Introduction.Gallstone disease is prevalent worldwide,and the incidence in Europe increased over the last decades.The median prevalence ranges from 5.9%to 21.9%,with the highest rates seen in Norway(21.9%)and the eastern part of Germany(19.7%)and the lowest rates in Italy(<7%)(1).In The Netherlands,over 100,000 patients are diagnosed with symptomatic gallstones annually,costing around 250 million euros,ranking gallstones disease in the top 10 of the most prevalent and costly gastrointestinal disorders(2).

Association between serosal intestinal microcirculation and blood pressure during major abdominal surgery

Background:In clinical practice,blood pressure is used as a resuscitation goal on a daily basis,with the aim of maintaining adequate perfusion and oxygen delivery to target organs.Compromised perfusion is often indicated as a key factor in the pathophysiology of anastomotic leakage.This study was aimed at assessing the extent to which the microcirculation of the bowel coheres with blood pressure during abdominal surgery.Methods:We performed a prospective and observational cohort study.In patients undergoing abdominal surgery,the serosal microcirculation of either the small intestine or the colon was visualized using handheld vital mi-croscopy(HVM).From the acquired HVM image sequences,red blood cell velocity(RBCv)and total vessel density(TVD)were calculated using MicroTools and AVA software,respectively.The association between microcircula-tory parameters and blood pressure was assessed using Pearson’s correlation analysis.We considered a two-sided P-value of<0.050 to be significant.Results:In 28 patients undergoing abdominal surgery,a total of 76 HVM images were analyzed.The RBCv was 335±96μm/s and the TVD was 13.7±3.4 mm/mm ^(2).Mean arterial pressure(MAP)was 71±12 mm Hg during microcirculatory imaging.MAP was not correlated with RBCv(Pearson’s r=−0.049,P=0.800)or TVD(Pearson’s r=0.310,P=0.110).Conclusion:In 28 patients undergoing abdominal surgery,we found no association between serosal intestinal microcirculatory parameters and blood pressure.