Acute necrotizing pancreatitis: can tigecycline be included in a therapeutic strategy?

INTRODUCTION

Acute necrotizing pancreatitis is a severe and life-threatening disease. Infection, which occurs in about 30% of cases, is the most feared complication. Antibiotic therapy is still discussed and there are no clear recommendation in literature. These clinical series underline the importance of having a clear antibiotic protocol, including tigecycline, in the management of acute necrotizing pancreatitis. Clinical series. Six patients with clinical and radiological diagnosis of necrotizing acute pancreatitis are treated in Emergency Surgery Department, following a conservative management, which includes fluid resuscitation, intensive care unit and radiological monitoring, ultrasound-guided percutaneous drainage and an antibiotic treatment protocol, that includes tigecycline. No one of the six patient undergo surgery (mean hospital stay: 44 days). In a six months follow-up all patients are alive and in good clinical conditions.

DISCUSSION

Infection is the most important factor which determinate prognosis and outcome of acute necrotizing pancreatitis. Antibiotic prophylaxis is still discussed and there are no clear antibiotic treatment guidelines in literature. Despite its side effects on pancreatic gland, tigecycline is successful in resolution of sepsis, caused by infected pancreatic necrosis.

CONCLUSIONS

Collaboration with infectivologist and a clear antibiotic protocol is fundamental to solve infected necrosis. Antibiotic treatment, set up as soon as possible, is successful in our six patients, as they recover without undergoing surgical procedures. Tigecycline offers broad coverage and efficacy against resistant pathogens for the treatment of documented pancreatic necrosis infection. However, further studies are necessary to fully understand the safety profile and efficacy of tigecycline.

Colonic stent placement as a bridge to surgery in patients with left-sided malignant large bowel obstruction. An observational study

BACKGROUND

Acute left-sided malignant colonic obstruction is common in elderly patients, in which emergency surgery is related with high morbidity and mortality rates, and often necessitates a two-step resection. Although the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described yet, there are almost two international important trials which are still in progress, the stenting technique is established to be, by the international literature, an useful treatment with low morbidity and mortality. It's also a bridge to surgery, since the insertion of a SEMS can decompress the obstruction, making bowel and patient preparation possible and facilitating singlestage surgical resection. Palliative stenting can improve quality of life when compared to surgery in patients with metastasis or high co-morbidity. The aim of this study is to analyze mortality, avoidance of stoma, short- and long-term survival in patient with malignant left-sided large bowel obstruction who underwent to stent placement in our Emergency Surgery Unit, which is operative since November 2010 in our city Hospital in Ferrara.

PATIENTS AND METHODS

Between November 2010 and December 2012 a total of 15 patients with acute left-sided malignant large bowel obstruction suitable for colonic stent application were admitted to Emergency Surgery Unit. Among these patients, 9 underwent to self-expanding metallic stent placement (group A), the other (group B) 6 patient underwent to emergency surgery. In this observational not-randomized study we analyzed the efficacy and safety of SEMS placement for patients either as a bridge to surgery or as a palliation, beside the short term and long term outcomes, versus those patients operated straight.

RESULTS

Self-expanding metallic stents were successfully implanted in 9 of the 15 patients with acute left-sided malignant large bowel obstruction. No acute procedure-related complication was observed. All the patients in group A kept the stent in place for an average of 7,7 days, then everyone underwent to surgery. A large bowel resection with one-time recanalization was performed in 8 of the 9 patients. None Hartmann resection was necessary. Only one underwent again to surgery because of a dehiscence, a stoma was necessary. Between the other 6 patients in group B who underwent directly to surgery, In one case was necessary an Hartmann resection, another one incurred in dehiscence of the anastomosis that required reoperation with stoma creation.

CONCLUSIONS

Placement of SEMS seems to be an useful alternative to emergent surgery in the management of acute left-sided bowel obstruction, both as a bridge to surgery and as a palliative procedure. SEMS can provide an effective and safe therapeutic option compared to emergency surgery, most of all in elderly patients, with a lower mortality rate, a significantly higher rate of primary anastomosis and the avoidance of stoma. However, to fully determine their role for these indications, more data and more high level evidence is required.

Spontaneous rupture of a hepatic epithelioid angiomyolipoma: damage control surgery. A case report

BACKGROUND

Angiomyolipoma (AML) is a rare mesenchymal tumor composed by blood vessels, adipose tissue and smooth muscle cells in variable proportions. Although it is most often diagnosed in the kidney, this tumor may originate from any part of the liver. It is often misdiagnosed as hepatocellular carcinoma (HCC) or other benign liver tumor. We describe a case of spontaneous rupture of hepatic angiomyolipoma in a young woman, with evidence of internal hemorrhage and hemoperitoneum.

CASE REPORT

Liver tumor rupture is a rare but real surgical emergency. In our case it has been managed according to the trauma principles of the damage control surgery. At the time of the observation, the patient presented an instable condition, so the decision-making was oriented toward a less invasive first step of liver packing instead of a more aggressive intervention such as one shot hepatic resection.

CONCLUSION

Damage control surgery with deep parenchymal sutures of the liver and pro-coagulant tissue adhesives packing abbreviates surgical time before the development of critical and irreversible physiological endpoints and permits a more confident second time surgery. This surgical management concept helps to reduce the mortality rate and the incidence of complications not only in traumatic liver damages, it works very well in spontaneous liver ruptures as well.