Abstracts Digestion 1992;52:67-137
Mortality in Pancreatitis
2
R. Andersson*, /. Ihse", A. Andrdn-Sandberg*, / ’. Kranlzb, P. Ldwenhielmb, I. Plantin Departments of "Surgery and bForensic Medicine, University of Lund, Sweden Acute pancreatitis (AP) is still associated with a sub stantial morbidity and mortality, though mortality rates reported vary widely. Little is known about death outside hospital due to AP. Patients. 14 out of 519 patients (2.7%: 12 men, 2 women: mean age 62 (37-83) years) admitted to the Department of Surgery. Lund, due to AP died during the period 1981-1990. In 36 other cases (30 men. 6 women: mean age 56 (29-83) years) death outside hospital was caused by AP 1984-1990. Results. Among patients with AP dying following admission to hospital, pancreatitis was induced by alcohol (6), biliary stones (5). trauma (1). postoperative (1) or unknown cause (1). Only one patient had had a previous attack of pancreatitis. Seven out of 14 patients were oper ated on. the first operation being done after 8 (4—15) days; in mean 2 (1-4) operations were performed per patient. Twelve out of 14 developed multiple system organ failure (MSOF). including respiratory (10). renal (12). cardiac (9) and hepatic (6) failure, gastrointestinal bleeding (2) and coagulopathia (3). Death was considered due to MSOF in 12 and circulatory failure in 2 and occurred after 21 (2-73) days. In the group with AP dying outside hospital, alcoholinduced pancreatitis dominated (27/36). All had necrotiz ing or hemorrhagic pancreatitis (2 patients had 1000 and 2000 ml of blood, respectively, in the peritoneal cavity at autopsy). Fifteen out of 27 with alcohol-induced AP had detectable levels of ethanol in cardiac blood. Conclusion. The mortality noted in AP is mainly due to MSOF. Repeated laparotomy is recommended in patients with severe AP and signsof necrosis/absccss. espe cially if seen together with developing organ failure. Mor tality in AP outside hospital is mainly caused by alcohol in subjects with known alcohol abuse.
Recurrence after Pancreatectomy for Pancreatic Cancer A. Andrén-Sandberg. J. Westerdahl, I. Ihse Department of Surgery. University of Lund. Sweden
The results of radical surgery for pancreatic cancer depend, like all other cancer surgery, on the technique used and the biology of the disease. We have analysed the site and time of recurrence after pancreatectomy for exocrine pancreatic cancer in 74 patients who died more than 6 months postoperatively. All patients had recurrent disease. 64 had local recurrence in the pancreatic bed and 68 had liver métastasés. Local recurrence without liver métastasés was found in 6 patients, and HI had liver métas tasés but no local recurrence. The time from operation to clinically evident recurrence and the postoperative survival time, respectively, were significantly longer for patients with local recurrence only. Although not statistically sig nificant there was a tendency (5 out of 8) for smaller, well differentiated tumors without spread outside the pancreas to give local recurrences without liver métastasés. We con clude that, in retrospect, the surgical procedures used were inappropriate and insufficient. To cure these patients a more radical operation and/or effective adjuvant treatment is needed.
3
Management of Cysts and Pseudocysts Complicating Acute and Chronic Pancreatitis: A Retrospective Study of 188 Patients M. Bardlet. J.P. Bernard. C. Bastid. J. Sahel Service d'hépatogastroentérologie. Hôpital SainteMarguerite. Marseille, France
Forty-five patients with 55 pancreatic pseudocysts (PC) complicating acute pancreatitis (AP) and I43 patients with 170 cysts (C) or pscudocysts (PC) complicating a
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Downloaded by: Stockholm University Library 130.237.165.40 - 12/3/2018 10:32:38 PM
1
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Antibiotics Penetration in Human Necrotizing Pancreatitis (NP) C. Bassi, P. Pederzoli, S. Vesenlini, G. Cavallini, P. Hovo, D. Lombardi, II. Abbas, F. Nifost, A. Beniid, £.37. Beriazzoni Surgical. Medical and Pharmacological Departments. Policlinico. University of Verona. Italy
The choice of antibiotics in preventing infected necrosis during NP should be based on their antimicrobial activity, penetration and therapeutic concentrations in necrotic pancreatic tissue (NPT). The aim of the study was to determinate whether or not antibiotics excreted by the normal pancreas are also excreted in human NP. reaching the tissue sites of the infection. Nine patients suffering from acute necrotizing pancreatitis were treated with imipenem (Im. 0.5 g). mezlocillin (M. 2 g). gentamicin (G. 0.08 g). amikacin (A. 0.5 g). pcfloxacin (P. 0.4 g) and metronidazole (Mz. 0.5 g). Serum and NPT samples were collected at the same time 2 h after in vitro drug administration, by CT-guided needle aspiration, intraoperatively and from surgical drains. Drug concentrations were determined by HPLC and microbio logical assay.
68
Abstracts
All antimicrobial drugs reached the NPT. but with varying degrees of penetration, this being low for amino glycosides (13%) and high in the case of P (89%) and Mz (99%). The concentrations of P (2.05 pg/ml) and Mz (6.3 ug/nil) in NPT were distinctly higher than the MICs for the organisms most commonly isolated in this disease: the tis sue concentrations of Im (3.35 pg/ml) and M (8.0 and 15.0 pg/ml) did not always exceed the MICs. whereas the ami noglycoside NPT concentrations (0.5 pg/ml) were inade quate. Repeated administrations seem to enhance drug penetration. These findings represent a further step for ward in our understanding of the therapeutic guidelines in NP.
5
Role of Imipenem (I) in Preventing Infected Necrosis (IN) during Acute Pancreatitis (NP). Results of the Italian Multicenter Study C. Bassi, V. Di Carlo, A. Zerbi, V. Gallon), G. Uomo, G. Fontana, R. I’ezzilli, P. Mascagni. G.P. Marzoli. F. Martin, S. Vesenlini, G. Cavallini, A. Campedelli, / ’. Pederzoli The Italian Multicenter Study Group (Verona, Bologna. Bolzano. Milano. Roma, Napoli). Italy
Clinical studies of effective antibiotics for prophylaxis on IN do not currently exist. Recent evidence of pancreatic penetration at therapeutic MICs of several antimicrobial drugs active against the usual flora found in IN has prompt ed us to carry out a study on I prophylaxis in NP. In 6 Ital ian centers, 74 consecutive patients (44 men. 30 women: mean age 52: range 20-84) with CT scans demonstrating NP (mean Ranson score 3.7) within 72 h from onset were randomly assigned to 2 groups receiving either non-antibi otic treatment (NA) or prophylactic 1(1) 0.5 g e.v. every 8 h for 2 weeks. Pancreatic sepsis was always detected by means of cultures (CT or US guided needle aspiration). The etiology was biliary in 37 cases, alcoholic in 24 and due to other causes in 13. H ie overall incidence of IN was 15 patients (20.3%). 10 (30.3%) on NA vs. 5 (12.2%) on I (p
Mortality in Pancreatitis
2
R. Andersson*, /. Ihse", A. Andrdn-Sandberg*, / ’. Kranlzb, P. Ldwenhielmb, I. Plantin Departments of "Surgery and bForensic Medicine, University of Lund, Sweden Acute pancreatitis (AP) is still associated with a sub stantial morbidity and mortality, though mortality rates reported vary widely. Little is known about death outside hospital due to AP. Patients. 14 out of 519 patients (2.7%: 12 men, 2 women: mean age 62 (37-83) years) admitted to the Department of Surgery. Lund, due to AP died during the period 1981-1990. In 36 other cases (30 men. 6 women: mean age 56 (29-83) years) death outside hospital was caused by AP 1984-1990. Results. Among patients with AP dying following admission to hospital, pancreatitis was induced by alcohol (6), biliary stones (5). trauma (1). postoperative (1) or unknown cause (1). Only one patient had had a previous attack of pancreatitis. Seven out of 14 patients were oper ated on. the first operation being done after 8 (4—15) days; in mean 2 (1-4) operations were performed per patient. Twelve out of 14 developed multiple system organ failure (MSOF). including respiratory (10). renal (12). cardiac (9) and hepatic (6) failure, gastrointestinal bleeding (2) and coagulopathia (3). Death was considered due to MSOF in 12 and circulatory failure in 2 and occurred after 21 (2-73) days. In the group with AP dying outside hospital, alcoholinduced pancreatitis dominated (27/36). All had necrotiz ing or hemorrhagic pancreatitis (2 patients had 1000 and 2000 ml of blood, respectively, in the peritoneal cavity at autopsy). Fifteen out of 27 with alcohol-induced AP had detectable levels of ethanol in cardiac blood. Conclusion. The mortality noted in AP is mainly due to MSOF. Repeated laparotomy is recommended in patients with severe AP and signsof necrosis/absccss. espe cially if seen together with developing organ failure. Mor tality in AP outside hospital is mainly caused by alcohol in subjects with known alcohol abuse.
Recurrence after Pancreatectomy for Pancreatic Cancer A. Andrén-Sandberg. J. Westerdahl, I. Ihse Department of Surgery. University of Lund. Sweden
The results of radical surgery for pancreatic cancer depend, like all other cancer surgery, on the technique used and the biology of the disease. We have analysed the site and time of recurrence after pancreatectomy for exocrine pancreatic cancer in 74 patients who died more than 6 months postoperatively. All patients had recurrent disease. 64 had local recurrence in the pancreatic bed and 68 had liver métastasés. Local recurrence without liver métastasés was found in 6 patients, and HI had liver métas tasés but no local recurrence. The time from operation to clinically evident recurrence and the postoperative survival time, respectively, were significantly longer for patients with local recurrence only. Although not statistically sig nificant there was a tendency (5 out of 8) for smaller, well differentiated tumors without spread outside the pancreas to give local recurrences without liver métastasés. We con clude that, in retrospect, the surgical procedures used were inappropriate and insufficient. To cure these patients a more radical operation and/or effective adjuvant treatment is needed.
3
Management of Cysts and Pseudocysts Complicating Acute and Chronic Pancreatitis: A Retrospective Study of 188 Patients M. Bardlet. J.P. Bernard. C. Bastid. J. Sahel Service d'hépatogastroentérologie. Hôpital SainteMarguerite. Marseille, France
Forty-five patients with 55 pancreatic pseudocysts (PC) complicating acute pancreatitis (AP) and I43 patients with 170 cysts (C) or pscudocysts (PC) complicating a
© 1V92 S. Kargcr AG. Basel 0012-2823/92/ 0522-0067 $2.75/0
Downloaded by: Stockholm University Library 130.237.165.40 - 12/3/2018 10:32:38 PM
1
4
Antibiotics Penetration in Human Necrotizing Pancreatitis (NP) C. Bassi, P. Pederzoli, S. Vesenlini, G. Cavallini, P. Hovo, D. Lombardi, II. Abbas, F. Nifost, A. Beniid, £.37. Beriazzoni Surgical. Medical and Pharmacological Departments. Policlinico. University of Verona. Italy
The choice of antibiotics in preventing infected necrosis during NP should be based on their antimicrobial activity, penetration and therapeutic concentrations in necrotic pancreatic tissue (NPT). The aim of the study was to determinate whether or not antibiotics excreted by the normal pancreas are also excreted in human NP. reaching the tissue sites of the infection. Nine patients suffering from acute necrotizing pancreatitis were treated with imipenem (Im. 0.5 g). mezlocillin (M. 2 g). gentamicin (G. 0.08 g). amikacin (A. 0.5 g). pcfloxacin (P. 0.4 g) and metronidazole (Mz. 0.5 g). Serum and NPT samples were collected at the same time 2 h after in vitro drug administration, by CT-guided needle aspiration, intraoperatively and from surgical drains. Drug concentrations were determined by HPLC and microbio logical assay.
68
Abstracts
All antimicrobial drugs reached the NPT. but with varying degrees of penetration, this being low for amino glycosides (13%) and high in the case of P (89%) and Mz (99%). The concentrations of P (2.05 pg/ml) and Mz (6.3 ug/nil) in NPT were distinctly higher than the MICs for the organisms most commonly isolated in this disease: the tis sue concentrations of Im (3.35 pg/ml) and M (8.0 and 15.0 pg/ml) did not always exceed the MICs. whereas the ami noglycoside NPT concentrations (0.5 pg/ml) were inade quate. Repeated administrations seem to enhance drug penetration. These findings represent a further step for ward in our understanding of the therapeutic guidelines in NP.
5
Role of Imipenem (I) in Preventing Infected Necrosis (IN) during Acute Pancreatitis (NP). Results of the Italian Multicenter Study C. Bassi, V. Di Carlo, A. Zerbi, V. Gallon), G. Uomo, G. Fontana, R. I’ezzilli, P. Mascagni. G.P. Marzoli. F. Martin, S. Vesenlini, G. Cavallini, A. Campedelli, / ’. Pederzoli The Italian Multicenter Study Group (Verona, Bologna. Bolzano. Milano. Roma, Napoli). Italy
Clinical studies of effective antibiotics for prophylaxis on IN do not currently exist. Recent evidence of pancreatic penetration at therapeutic MICs of several antimicrobial drugs active against the usual flora found in IN has prompt ed us to carry out a study on I prophylaxis in NP. In 6 Ital ian centers, 74 consecutive patients (44 men. 30 women: mean age 52: range 20-84) with CT scans demonstrating NP (mean Ranson score 3.7) within 72 h from onset were randomly assigned to 2 groups receiving either non-antibi otic treatment (NA) or prophylactic 1(1) 0.5 g e.v. every 8 h for 2 weeks. Pancreatic sepsis was always detected by means of cultures (CT or US guided needle aspiration). The etiology was biliary in 37 cases, alcoholic in 24 and due to other causes in 13. H ie overall incidence of IN was 15 patients (20.3%). 10 (30.3%) on NA vs. 5 (12.2%) on I (p
