Journal of hepato-biliary-pancreatic sciences
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J Hepatobiliary Pancreat Sci · Mar 2010
Comparative StudyIs an estimation of physiologic ability and surgical stress able to predict operative morbidity after pancreaticoduodenectomy?
Mortality rates after pancreaticoduodenectomy (PD) are below 4% in high volume centers, although morbidity rates still remain high. Therefore, it is important to clarify a predictor associated with operative morbidity after PD. The estimation of physiologic ability and surgical stress (E-PASS) score has been developed for comparative audit in general surgical patients. ⋯ E-PASS scoring system is useful to evaluate for morbidity after PD. Neoadjuvant chemotherapy and IORT could be adapted without significant extra risk for surgical complication.
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J Hepatobiliary Pancreat Sci · Mar 2010
Case ReportsTotal vascular hepatic exclusion for tumor resection: a new approach to the intrathoracic inferior vena cava through the abdominal cavity by cutting the diaphragm vertically without cutting the pericardium.
For the resection of advanced liver tumors in which the tumor thrombus extends into the intrathoracic inferior vena cava (IVC) above the diaphragm, surgeons need very skillful techniques and much experience. However, after detachment of the line of fusion of the pericardium to the diaphragm (LFPD), the intrathoracic IVC can be exposed easily. We herein present this novel surgical method, an approach to the intrathoracic IVC through the abdominal cavity. ⋯ He underwent left hepatectomy with partial resection of the IVC and intravascular tumor thrombectomy under total hepatic vascular exclusion (THVE) without the use of cardiopulmonary bypass (CPB). Before THVE, we approached the IVC through the abdominal cavity with vertical dissection of the diaphragm after detachment of the LFPD without cutting the pericardium or performing median sternotomy. This procedure could be very beneficial and helpful for many liver surgeons.
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Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. ⋯ Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.
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When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. ⋯ The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.
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The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. ⋯ This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.