Timing and indications for surgical intervention in infective endocarditis

This paper reviews current knowledge on the indications for and timing of cardiac surgery in patients with infective endocarditis. The main indications for surgery are haemodynamic compromise, persisting infection, peripheral embolisation, large size of vegetations, large valvular and paravalvular damage and infections caused by certain microorganisms.     

Acute necrotic pancreatitis: toward restriction of surgical indications

Fifty-two patients operated for acute necrotising pancreatitis are reported. All severely-ill patients, operated early in order to perform a necrosectomy, died subsequently. Patients without severe illness were operated either for a complication of their pancreatic necrosis or electively for biliary lithiasis. The postoperative mortality was 29 p. 100 and 0 p. 100 respectively. Pancreatic necrosectomies were associated with a high morbidity whether performed for complications (64 p. 100) or during elective biliary surgery (33 p. 100). From this study, it appears that there is no indication for early necrosectomy in the severe forms of acute necrotising pancreatitis. However, pancreatic abscess remains a formal indication for drainage. It seems also justified to perform elective surgery without necrosectomy for biliary lithiasis complicated by acute necrotising pancreatitis.     

Outcome of surgical treatment for chronic calcifying pancreatitis

OBJECTIVE: To evaluate the short and long-term results of surgical treatment of calcifying chronic pancreatitis in our center. PATIENTS AND METHODS: We studied 55 consecutive patients operated on for chronic calcifying pancreatitis during a period of 12 years. The mean follow-up period was 6.2 years. Main outcome measures were operative mortality and morbidity, degree of pain control, diabetes onset, survival, and causes of death. RESULTS: The etiology was alcoholic in 48 patients and idiopathic in seven patients. A resection was performed in 78% of cases and a by-pass procedure was performed in 22%. Operative mortality was 3.6%; morbidity was 21.8%. A ductal adenocarcinoma was found in 3.6% of cases. The alcohol withdrawal rate was 78%. Complete pain control was achieved in 71.4% of the patients. Among diabetes, cirrhosis, type of surgery, smoking and alcohol abuse history, only alcohol withdrawal was associated with pain control (p < 0.03). A late reintervention was needed in only one patient in the by-pass group. Five and 10-year survival rates for the entire population were 80% and 61%, respectively. Among alcohol, cirrhosis, diabetes, and type of surgery, only the former was associated with survival (p < 0.003). Five-year actuarial survival was 55.6% for patients who continued drinking compared with 86.3% for ex-alcoholics. CONCLUSIONS: Surgical resection should be performed when required by the anatomical conditions because it was associated with good long-term pain control and low postoperative and late morbidity. Alcohol withdrawal has a key role for effective control of pain and prolonged survival.     

Endoscopic treatment for chronic pancreatitis: indications, technique, results

Endoscopic treatment associated with or without extracorporeal shock wave lithotripsy (ESWL) for chronic pancreatitis has been employed for about 20 years. Although two randomized control trials have revealed the greater effectiveness of surgery as compared to endoscopic treatment for chronic pancreatitis, a considerable number of patients have successfully obtained complete and long-term relief from pain by the less invasive endoscopic treatment. In this review, we discuss the indications, techniques and results of endoscopic treatment and ESWL for painful chronic pancreatitis. We also discuss the characteristic clinical features that are predictive of a good response to endoscopic treatment and ESWL.     

重症急性胰腺炎的外科干预策略

重症急性胰腺炎病程中的"2次死亡高峰"是临床治疗中的一大挑战.早期为炎症反应期,应进行以维护器官功能为核心的多学科综合救治;后期以感染性并发症为主,外科医师对于外科干预指征、时机及方式的掌控尤为重要.重症急性胰腺炎的治疗已逐步形成为一个由多学科参与、个体化的综合治疗模式,临床中应建立以疾病为核心的综合救治平台.文章就近...     

Current best practices and guidelines indications for surgical intervention in infective endocarditis

Optimal diagnosis and management of patients with infective endocarditis requires sound clinical judgment based on extensive experience. This is especially important in regard to the indications and timing for surgery. To achieve the best possible outcomes, surgical intervention during treatment is required in 25% to 30% of patients with infective endocarditis. Heart failure and progressive left-sided valvular dysfunction are the most common indications for operation. Valve repair should be considered as an alternative to valve replacement whenever feasible, especially in younger patients. Successful management of perivalvular abscesses and prosthetic valve infections requires radical removal of infected tissue followed by reconstructive procedures performed by experienced surgeons. Emergency or urgent surgery should seldom be delayed.     

Management of benign strictures of the extrahepatic bile duct due to chronic pancreatitis and surgical intervention

In the Endoscopic Forum Japan 2011 (EFJ 2011), we focused on the management of biliary strictures derived from chronic pancreatitis and surgical intervention. We concluded that regardless of causes of strictures, a large bore single plastic stent is better as a first choice of stenting. As a next step, multiple plastic stents may be preferable compared to a covered self-expandable metallic stent in case of unexpected adverse events and cost of stent. In the near future, we believe that not only progress of treatment technique and accessories but also good understanding of the pathology of biliary strictures will lead to the best management.     

青少年慢性胰腺炎的诊断及外科治疗

目的探讨青少年慢性胰腺炎的临床特点、诊断及外科治疗.方法回顾性分析1993年3月～ 2001年3月手术治疗的7例青少年慢性胰腺炎患者的临床资料.结果青少年患者大多存在先天性胰胆管发育异常(胰腺分裂1例,胰胆管合流异常1例,胆总管囊肿2例).主要症状为反复上腹痛.B超、CT、ERCP和超声内镜(EUS)等影像学检查有助于早期诊断,其诊断阳性率分别为57.1%(4/7)、71.4%(5/7)、100%(5/5)和100%(4/4).7例患者均接受了手术治疗,其中行胰头部分切除、胰管空肠侧侧吻合术(Frey's)1例,胰管切开取石、胰管空肠侧侧吻合术3例(其中Partington's术式2例,Puestow's术式1例),Oddi括约肌切开成形术1例,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术 + 保留十二指肠的胰头切除术(DPPHR)2例.术后近期腹痛均缓解.所有患者均获随访,随访时间2 ～ 9年,平均4.7年.1例于术后8个月症状复发,再次手术行胰尾切除,症状缓解.多数患者疗效满意.结论青少年慢性胰腺炎的病因不同于成人慢性胰腺炎,手术时机的掌握和手术方法的选择对患者的生活质量和疾病进程的控制至关重要.     

青少年慢性胰腺炎的诊断及外科治疗

目的探讨青少年慢性胰腺炎的临床特点、诊断及外科治疗。方法回顾性分析1993年3月～2001年3月手术治疗的7例青少年慢性胰腺炎患者的临床资料。结果青少年患者大多存在先天性胰胆管发育异常(胰腺分裂1例,胰胆管合流异常1例,胆总管囊肿2例)。主要症状为反复上腹痛。B超、CT、ERCP和超声内镜(EUS)等影像学检查有助于早期诊断,其诊断阳性率分别为57．1％(4／7)、71．4％(5／7)、100％(5／5)和100％(4／4)。7例患者均接受了手术治疗,其中行胰头部分切除、胰管空肠侧侧吻合术(Frey's)1例,胰管切开取石、胰管空肠侧侧吻合术3例(其中Partington's术式2例,Puestow's术式1例),Oddi括约肌切开成形术1例,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术 保留十二指肠的胰头切除术(DPPHR)2例。术后近期腹痛均缓解。所有患者均获随访,随访时间2～9年,平均4．7年。1例于术后8个月症状复发,再次手术行胰尾切除,症状缓解。多数患者疗效满意。结论青少年慢性胰腺炎的病因不同于成人慢性胰腺炎,手术时机的掌握和手术方法的选择对患者的生活质量和疾病进程的控制至关重要。     

Long-term results after surgical management of chronic pancreatitis.

BACKGROUND/AIMS: Long-term outcome in surgery for chronic pancreatitis remains relatively unknown. METHODOLOGY: Between 1963 and 1993, we performed 123 pancreatic resections and 35 drainage procedures for severe chronic pancreatitis. We reviewed 131 patients with a mean follow-up of 48 months (4 months to 18 years). RESULTS: Actual 10-year survival was 82% for nonalcoholic patients and 51% for alcoholic pancreatitis. Pain was successfully treated in 71% with pancreatic resection and in 42% with drainage procedures (p<0.01). Although post-operative diabetes mellitus occurred in 56% of patients after pancreatic resection, long-term nutritional status was similar after pancreatic resection and drainage procedures. Weight gain could be observed in 75 patients (47%) and quality-of-life was good to excellent in 97 patients (74%). CONCLUSIONS: In conclusion, long-term survival was mainly conditioned by the etiology of the disease. Pancreatic resections were more successful in treating intractable pain than drainage and required fewer re-interventions. As presumed, resections were associated with a higher rate of diabetes mellitus, but this, however, had no impact on long-term nutritional status and quality-of-life.     

The natural history of splenic vein thrombosis due to chronic pancreatitis: indications for surgery

Eleven patients with angiographically demonstrated splenic vein thrombosis associated with chronic pancreatitis were followed for an average of 6.5 yr to determine the natural history of this condition. Repeat angiography was performed in five patients. Significant gastric or gastroesophageal varices were noted in six cases. In another patient, peri-colonic varices and spleno-portal collaterals were demonstrated. Two patients bled massively during follow-up; one from gastric varices and one from colonic varices. Another patient, with known gastric varices, intermittent hematochezia and iron deficiency anemia, underwent surgery. All three patients responded well to splenectomy. Since three of the seven patients with splenic vein thrombosis and significant varices eventually required surgical correction, it may be that the long-term risk of gastrointestinal bleeding exceeds the risks of elective splenectomy in these patients.     

Timing of surgical intervention in chronic mitral regurgitation

Determination of the optimal time for surgical intervention in chronic mitral regurgitation has remained controversial. There are similarly important factors in favor of temporizing with medical treatment alone as there are in support of relatively early surgery (Table 1). Since rheumatic valvulitis may play a subordinate role, in contrast to etiologies such as myxomatous degeneration of the mitral valve, rupture of chordae tendineae, papillary muscle dysfunction due to coronary artery disease and other causes, left ventricular function is generally determined by the adaptations of the myocardium to the volume overload, or to ischemia or infarction from coronary artery disease rather than to a concomitant myocarditis. Based on actuarial survival curves in symptomatic patients with combined mitral regurgitation and stenosis or mitral regurgitation alone, it can be assumed that surgery can result in improved survival, in particular if a reconstructive mitral valve procedure rather than prosthetic valve replacement is performed. Medical treatment is carried out with digitalis to enhance myocardial contractility, diuretics and vasodilators to reduce pre- and afterload with resultant diminished effective mitral orifice area and regurgitant volume, lowering of pulmonary artery and pulmonary venous pressures and an increase in systemic cardiac output. Presently, however, there is no convincing evidence that symptom-status is improved or the natural history favorably affected over a number of years. For assessment of left ventricular myocardial function the end-systolic pressure/volume or the end-systolic stress/volume index appear preferable. Values of the latter less than or equal to 2.2 are associated with increased postoperative mortality and improbable improvement in functional status. Additionally, patients with an ejection fraction less than 40% or end-diastolic volume greater than 140 ml/m2 as well as those with end-diastolic dimension greater than 8 cm or end-systolic dimension greater than 5.5 cm have less favorable postoperative survival or further deterioration in ventricular function. Impaired right ventricular function secondary to the increased afterload imposed by pulmonary hypertension generally can be normalized postoperatively. Depression of right ventricular myocardial contractility is not, however, a common pathophysiologic feature in chronic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

Background/objectivesChronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.MethodsAn international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach’s alpha reliability coefficient.ResultsStrong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40–55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.ConclusionsThis international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.