Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases

Background

There has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date.

Methods

The predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006.

Results

Two hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8–18 days). Initial empiric antibiotic choice did not influence outcomes.

Conclusion

Streptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.     

Rapid endoscopic improvement is important for 1-year avoidance of colectomy but not for the long-term prognosis in cyclosporine A treatment for ulcerative colitis

Background

Intravenous (IV) cyclosporine A (CSA) is one of the treatments of choice for patients with steroid-refractory severe ulcerative colitis (UC). In this study, we evaluated the overall experience with CSA treatment in UC patients, from their initial response to long-term prognosis.

Methods

The medical records of 72 patients admitted to our hospital with a severe UC flare-up and treated with IV CSA between November 1996 and October 2008 were reviewed retrospectively. The initial response to CSA was assessed using a clinical activity index, and colectomy was assigned as the endpoint for the long-term prognosis.

Results

Overall, 53 of 72 (73.6%) patients responded initially to CSA. We could not determine any specific parameters that predicted an initial response. A life-table analysis for all patients revealed that 54.4% of patients required a colectomy within 11 years. The long-term risk of surgery was associated with a shorter disease duration, history of adverse reactions against medications and lack of immunomodulator use. In addition, endoscopic improvement at day 14 was associated with colectomy at 1 year, but not with the long-term prognosis.

Conclusions

Although CSA can exert high initial efficacy for severe attacks of UC, >50% of patients who relapse require a colectomy. Specifically, mucosal healing evaluated by endoscopy was associated with the 1-year colectomy rate. In contrast, a history of adverse drug reactions was correlated with the long-term colectomy rate. Therefore, we propose that treatment of severe UC with CSA requires consideration of both initial remission and long-term maintenance as management goals.     

The roles of surgery and EMA/CO chemotherapy regimen in primary refractory and non-refractory gestational trophoblastic neoplasia

Purpose

To determine the characteristics and outcome of patients with refractory gestational trophoblastic neoplasia (GTN) after primary chemotherapy (CTx).

Methods

The outcome of low- and high-risk patients with refractory GTN (n?=?14, 37%) was compared to those with non-refractory GTN (n?=?24, 63%). Methotrexate treatment was used for patients with low-risk disease and EMA/CO for patients with high-risk disease.

Results

Median follow-up time was 53?months (range 1–173?months). All non-refractory patients and 11 refractory patients (79%) survived (p?=?0.015). Factors related to resistance to primary CTx was age (p?=?0.012), duration between causal pregnancy and initial treatment (p?=?0.003), surgery (p?=?0.014), hCG level before CTx (p?=?0.09) and half-life of hCG (p?=?0.061). Six out of 10 low-risk refractory patients treated with EMA/CO regimen in the second-line setting had been followed by no evidence of disease. Nine of 38 (24%) patients underwent surgery (TAH?±?BSO) for GTN. All of the patients treated with surgery were in the non-refractory group, but none of refractory patients underwent surgery (p?=?0.014).

Conclusions

Surgery and EMA/CO regimen are one of the main factors that play a role in the management of refractory low-risk GTN.     

Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis

STUDY OBJECTIVE: IV antibiotic therapy for 2 to 6 weeks followed by 6 to 12 months of oral antibiotic therapy is usually recommended for the treatment of thoracic actinomycosis. The objective of this study was to evaluate the duration of IV and oral antibiotic therapy for thoracic actinomycosis. METHODS: We present a retrospective case series of 28 patients with thoracic actinomycosis as confirmed by histopathology from October 1994 through December 2003. RESULTS: After diagnosis of actinomycosis, 54% (15 of 28 patients) received antibiotic therapy alone. The duration of IV antibiotic therapy ranged from 0 to 18 days (median, 2 days; interquartile range [IQR], 0 to 3 days), and the duration of oral antibiotic treatment ranged from 76 to 412 days (median, 167 days; IQR, 142 to 214 days) in patients who received antibiotics alone. Combination surgical and antibiotic therapy occurred in 46% (13 of 28 patients). The duration of IV antibiotic therapy ranged from 3 to 17 days (median, 8 days; IQR, 5 to 13 days), and the duration of oral antibiotic therapy ranged from 0 to 534 days (median, 150 days; IQR, 3.5 to 289 days) in these patients. Clinical cures were achieved in 96% (27 of 28 patients). There was no clinical evidence of recurrence during follow-up period at our hospital (median, 23 months; IQR, 9 to 44 months) in 21 patients, excluding 7 patients who were transferred to referring hospitals after completion of antibiotic therapy (n = 6) or during antibiotic therapy (n = 1). CONCLUSIONS: Thoracic actinomycosis is best treated with individualized therapeutic modalities, depending on factors such as the initial burden of disease, the performance of resectional surgery, and the clinical and radiologic responses to therapy. The traditional recommendation of IV antibiotic therapy for 2 to 6 weeks followed by oral antibiotic therapy for 6 to 12 months is not always necessary for all thoracic actinomycosis patients.     

Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients

Introduction

Data highlighting the long-term outcome following an initial episode of right-sided colonic diverticulitis is lacking. This study aims to evaluate and follow up on all patients with right-sided colonic diverticulitis.

Methods

A retrospective review of all patients who were discharged with a diagnosis of right-sided colonic diverticulitis from January 2003 to April 2008 was performed.

Results

A total of 226 patients, with a median age of 49 (range, 16–93)?years, were admitted for acute right-sided colonic diverticulitis. The majority of the patients (n?=?198, 87.6 %) had mild diverticulitis (Hinchey Ia and Ib). Seventy-three (32.3 %) patients underwent emergency surgery. The indications of surgery were predominantly suspected appendicitis (n?=?50, 22.1 %) and perforated diverticulitis (n?=?16, 7.1 %). Right hemicolectomy was performed in 32 (43.8 %) patients, while appendectomy, with or without diverticulectomy, was performed in the rest (n?=?41, 56.2 %). There were seven patients who underwent elective right hemicolectomy after their acute admissions.Over a median duration of 64 (12–95)?months, there were only nine patients who were readmitted 12 times for recurrent diverticulitis at a median duration of 17 (1–48)?months from the index admission. The freedom from failure (recurrent attacks or definitive surgery (right hemicolectomy)) at 60 months was 92.0 % (95 % Confidence interval 86.1 %–97.9 %).

Conclusion

Right-sided diverticulitis is commonly encountered in the Asian population and often gets misdiagnosed as acute appendicitis. If successfully managed conservatively, the long-term outcome is excellent.     

Conservative treatment of intrarectal mesh migration after ventral laparoscopic rectopexy for rectal prolapse

Objective

Ventral rectopexy is a validated treatment for rectal prolapse with a low morbidity rate but a risk of intrarectal mesh migration. The purpose of this study was to report the results of local transanal mesh excision for intrarectal mesh migration after ventral rectopexy.

Methods

Between January 2004 and March 2011, 312 patients underwent laparoscopic ventral rectopexy in two hospitals. Six patients were treated for intrarectal mesh migration.

Results

Delay between ventral rectopexy and the onset of symptoms was 53 months (4–124 months). All patients have symptoms. Imaging revealed a pelvic abscess in two cases. Intrarectal mesh migration was confirmed by anorectoscopy or clinical examination. Five patients were only treated by local transanal partial mesh excision, and one required a colostomy. Morbidity and mortality were zero. The median hospitalization time was 5 days (3–8 days). After a median postoperative follow-up period of 9 months (1–40 months), one recurrence was observed 2 months after surgery.

Conclusion

Local transanal mesh excision for intrarectal mesh migration after laparoscopic ventral rectopexy is a feasible conservative treatment. This simple treatment produced a cure of the pelvic inflammation and closure of the fistula without compromising a more aggressive secondary treatment which was not necessary in our series.     

Long-term outcomes of primary ocular adnexal lymphoma treatment with intraorbital rituximab injections

Purpose

We recently reported on the efficacy of intralesional rituximab for treating primary ocular adnexal lymphoma in a pilot study. After treatment, a complete response was observed in two of five patients, a partial response in one patient, and lesion recurrence in two patients. In this study, we evaluate the long-term follow-up of the five previously treated patients as well as the response of two new patients to an augmented dose of rituximab.

Methods

We followed up the five patients who were treated with rituximab during the initial pilot study. Two additional patients were also enrolled and treated with four intraorbital injections of 10 mg rituximab once a week for 1 month (total dose of 40 mg). Median follow-up period was 4 years for the first five patients and 1 year for the last two patients.

Results

Lymphoma did not relapse in the two patients who originally responded immediately to treatment. Of the initial partial responders, one became disease-free after additional rituximab treatment, and one experienced a standardized uptake value reduction, as measured with positron emission tomography–CT. One patient who experienced abdominal and pulmonary localization 7 months later showed no local recurrence. The two newly enrolled patients had complete remission after the first cycle of treatment and no disease recurrence eight and 11 months later, respectively.

Conclusions

This study suggests that intralesional administration of rituximab for treating localized ocular adnexal CD20+ lymphomas could be an effective front-line therapeutic option with negligible side effects and a good response rate and duration.     

Fever-based antibiotic therapy for acute cholangitis following successful endoscopic biliary drainage

Background

The current management of acute cholangitis consists of antibiotic therapy in combination with biliary drainage. However, the optimal duration of antibiotic therapy after the resolution of clinical symptoms by biliary drainage is unclear. We aimed to evaluate whether discontinuing antibiotic therapy for acute cholangitis immediately after the resolution of clinical symptoms, achieved by endoscopic biliary drainage, was safe and effective.

Methods

This prospective study included patients with moderate and severe acute cholangitis. Cefmetazole sodium and meropenem hydrate were used as initial antibiotic therapy for patients with moderate and severe acute cholangitis, respectively. All patients underwent endoscopic biliary drainage within 24?h of diagnosis. When the body temperature of <37°C was maintained for 24?h, administration of antibiotics was stopped. The primary endpoint was the recurrence of acute cholangitis within 3?days after the withdrawal of antibiotic therapy.

Results

Eighteen patients were subjected to the final analysis. The causes of cholangitis were bile duct stone (n?=?17) and bile duct cancer (n?=?1). The severity of acute cholangitis was moderate in 14 patients and severe in 4. Body temperature of <37°C was achieved in all patients after a median of 2?days (range 1?C6) following endoscopic biliary drainage. Antibiotic therapy was administered for a median duration of 3?days (range 2?C7). None of the patients developed recurrent cholangitis within 3?days after the withdrawal of antibiotics.

Conclusions

Fever-based antibiotic therapy for acute cholangitis is safe and effective when resolution of fever is achieved following endoscopic biliary drainage.     

Role of adjuvant surgery for patients with initially unresectable pancreatic cancer with a long-term favorable response to non-surgical anti-cancer treatments: results of a project study for pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

Purpose

A multicenter survey was conducted to explore the role of adjuvant surgery for initially unresectable pancreatic cancer with a long-term favorable response to non-surgical cancer treatments.

Methods

Clinical data including overall survival were retrospectively compared between 58 initially unresectable pancreatic cancer patients who underwent adjuvant surgery with a favorable response to non-surgical cancer treatments over 6 months after the initial treatment and 101 patients who did not undergo adjuvant surgery because of either unchanged unresectability, a poor performance status, and/or the patients’ or surgeons’ wishes.

Results

Overall mortality and morbidity were 1.7 and 47 % in the adjuvant surgery group. The survival curve in the adjuvant surgery group was significantly better than in the control group (p < 0.0001). The propensity score analysis revealed that adjuvant surgery was a significant independent prognostic variable with an adjusted hazard ratio (95 % confidence interval) of 0.569 (0.36–0.89). Subgroup analysis according to the time from initial treatment to surgical resection showed a significant favorable difference in the overall survival in patients who underwent adjuvant surgery over 240 days after the initial treatment.

Conclusion

Adjuvant surgery for initially unresectable pancreatic cancer patients can be a safe and effective treatment. The overall survival rate from the initial treatment is extremely high, especially in patients who received non-surgical anti-cancer treatment for more than 240 days.     

Laparoscopic sphincter-preserving surgery (intersphincteric resection) after neoadjuvant imatinib treatment for gastrointestinal stromal tumor (GIST) of the rectum

Background

Gastrointestinal stromal tumors (GISTs) of the rectum are rarely found, and radical surgery such as abdominoperineal resection would be necessary for large rectal GIST. On the other hand, therapy for GIST has changed significantly with the use of imatinib. Neoadjuvant imatinib therapy may reduce tumor size and may potentially prevent extended surgery. Moreover, when sphincter-preserving surgery is carried out laparoscopically, it can be performed as minimally invasive surgery with preservation of the anus.

Methods

From 2008 to 2011, five patients with rectal GIST were treated in our hospital. All patients received preoperative imatinib treatment (400 mg/day) and underwent laparoscopic sphincter-preserving surgery after 4–12 months of this treatment.

Results

Initial median tumor size was 31 mm (range, 24–88). At the time of operation, the median tumor size was 24 mm (range, 11–52). Sphincter-preserving surgery was performed in all patients. Three patients underwent laparoscopic intersphincteric resection (ISR), and two patients underwent transanal full-thickness local resection and recto-anal anastomosis following laparoscopic ISR. Macroscopically complete resection was achieved, and microscopically, the resection margin was not involved of residual tumors. The median duration of postoperative hospital stay was 16 days (range, 13–30). No recurrence occurred in all patients during 1 to 4 years.

Conclusions

The present study suggests that neoadjuvant imatinib therapy might be effective to prevent extended surgery for rectal GIST, and laparoscopic sphincter-preserving surgery is safe and technically feasible. We recommend a combination of neoadjuvant imatinib therapy and laparoscopic ISR for locally advanced rectal GIST.     

Primary malignant cardiac tumors

Purpose

The literature on primary malignant cardiac tumors is relatively limited because of their rare incidence. This study aimed to provide a proposed treatment strategy for primary malignant cardiac tumors.

Methods

The follow-up outcomes of 29 patients with primary malignant cardiac tumors operated, and 8 primary malignant cardiac tumors considered not operable from 1985 to 2013 in the First Affiliated Hospital of China Medical University were retrospectively analyzed.

Results

Of operation receivers, ten patients had positive surgical margins and nineteen patients had negative surgical margins. Eleven patients received a post-operative neoadjuvant chemotherapy. Patients rejected to surgery had a lower survival compared with operation receivers (15 vs 23 months, P = 0.011). However, there were no significant differences in survival in patients rejected to surgery than in patients who had positive surgical margins (15 vs 16 months, P = 0.874). Patients who had positive surgical margins had a median overall survival duration of only 16 months, whereas patients with negative surgical margins had a median overall survival duration of 27 months (P = 0.002). There were no significant differences in survival in patients with receiving a post-operative adjuvant chemotherapy than in the rest of the population (20 vs 25 months, P = 0.150).

Conclusions

The prognosis for patients with primary malignant cardiac tumors remains very poor. Each patient should be managed on an individual basis, and variety of treatment strategy should be performed. Maximizing the possibility of obtaining negative surgical margins may prolong survival.     

Surgical treatment of lymph node metastases from hepatocellular carcinoma

Background

No consensus has been reached on the feasibility and efficacy of surgery for lymph node metastases (LNM) from hepatocellular carcinoma (HCC).

Methods

Of 2189 patients with HCC treated at our hospital between July 1992 and March 2008, we retrospectively reviewed the medical dossiers of the 18 patients (0.8%) who underwent lymph node resection and were pathologically diagnosed to have LNM from HCC. The surgical procedure for LNM was selective lymphadenectomy of those lymph nodes suspected to harbor metastasis. The feasibility and efficacy of selective lymphadenectomy was examined, and clinicopathological factors were analyzed with the aim of determining which patients would most benefit from surgery.

Results

Eighteen patients underwent surgery without mortality or liver failure. Morbidities were found in four patients (22.2%). The median survival time (MST) after surgery was 29 months [95% confidence interval (CI) 21–38 months). The 1-, 3-, and 5-year overall survival rates were 85, 42, 21%. The median progression-free survival (PFS) after surgery was 6 months (95% CI 1–11 months), and the median extrahepatic PFS was 16 months (95% CI 13–18 months). Single LNM was the only favorable prognostic factor after surgery (Hazard ratio 0.082, 95% CI 0.008–0.83).

Conclusion

Selective lymphadenectomy of LNM from HCC was a feasible and efficacious procedure. Survival rates can be expected to improve after selective lymphadenectomy of single LNM.     

Brain metastases as the first symptom of lung cancer: a clinical study from an Asian medical center

Objective

Brain metastasis as the first symptom of lung cancer is a unique clinical entity. We conducted a retrospective study to investigate the clinical characteristics and survival of patients with lung cancer whose first symptom was brain metastases in an Asian population.

Methods

A retrospective study of 186 such patients who had been admitted to one institution in China between January 1, 2003 and December 30, 2008 was performed. The following data were collected and analyzed: manifesting signs and symptoms, imaging studies, extracerebral metastases, initial diagnosis, treatment, and patient survival.

Results

This sample population exhibited high rates of misdiagnosis upon initial presentation (46.8 %). Fifty-seven (30.6 %) patients presented with silent extracerebral metastases. Pathologies among this cohort varied, and adenocarcinomas were most commonly observed. Most patients received surgical resection, and some patients had additional whole-brain radiotherapy or stereotactic radiosurgery. The median survival time for the entire cohort was 15 months (95 % confidence interval, 12.9–17.1 months). Survival rates for 1, 2, and 5 years were 58.2, 34.2, and 6.5 %, respectively. The median survival time was 15, 14, 19, and 7 months for the gross total resection, incomplete resection, surgery + whole-brain radiotherapy, and surgery + stereotactic radiosurgery groups, respectively.

Conclusions

Brain metastasis as the first symptom of lung cancer is a distinct clinical entity. Although overall survival was poor, combined treatments based on surgery for selected patients were reasonable with the exception of a minority who experienced long-term survival.     

Recurrent intrahepatic cholangiocarcinoma: single-center experience using repeated hepatectomy and radiofrequency ablation

Background

Intrahepatic cholangiocarcinoma (IHC) is a rare liver malignancy with a rising incidence worldwide. Since no standard treatment has been established so far, the aim of this study was to assess the safety and efficacy of repeated liver resection and/or radiofrequency ablation (RFA) in selected cases with recurrent IHC.

Patients and methods

The outcome of 13 patients who had been treated at least once for recurrent IHC by repeated liver resection and/or RFA was retrospectively analyzed. A total of 12 repeated liver resections and 8 radiofrequency ablations were performed in these patients between 2002 and 2008.

Results

After a median follow-up period of 28 months after primary liver resection (12–69 months), seven patients (54%) are still alive and three of these patients (23% of the entire cohort) are regarded as disease-free. The median survival for all patients was 51 months (12–69 months). One- and three-year survival after primary surgery was 92 and 52%, respectively, with an overall complication rate of 7.6%.

Conclusion

According to the present data, repeated liver resection and radiofrequency ablation are feasible in select patients with recurrent IHC. Both procedures can be regarded as safe and might lead to a prolongation of patient survival.     

Clinical outcomes of two-field lymphadenectomy for patients with clinical stage IA carcinoma of the thoracic esophagus

Background

The optimal treatment for early stage carcinoma of the thoracic esophagus is undecided and remains debatable. This report documents the results of a series of patients with clinical stage IA carcinoma of the thoracic esophagus treated at our institute with esophagectomy and two-field lymphadenectomy (2FL).

Methods

We analyzed 70 patients with clinical stage IA carcinoma who underwent radical esophagectomy with 2FL.

Results

The overall 5-year survival rate of the 70 patients was 81 %. Seventeen of the 70 patients (24 %) had lymph node metastasis. The overall 5-year survival rate of the 53 patients with no metastatic nodes (87 %) was significantly better than that of the 17 patients with positive nodes (65 %; p = 0.022). The operative morbidity was 44 %. Recurrence was recognized in 17 patients (24 %). The median disease-free interval (DFI) until recurrence was 20.5 months. With respect to the initial tumor recurrence, among the 16 patients with a recurrence, there were 9 with a cervical lymph node recurrence, 3 with a hematogenous recurrence, 2 with a combined recurrence, 1 with an abdominal lymph node recurrence in the paraaortic site, and 1 in the anastomotic site. The median DFI and survival times of the patients with a cervical lymph node recurrence were 26 and 55 months, respectively. Of the 9 patients with a cervical lymph node recurrence, 3 disease-free patients survived: 2 received surgery and 1 received radiotherapy.

Conclusions

Two-field lymphadenectomy might be enough for patients with clinical stage IA carcinoma of the middle and lower thoracic esophagus in regard to prognosis, but close follow-up for lymph node recurrence, especially at the cervical site, should be conducted.     

Intravenous immunoglobulins for relapses of systemic vasculitides associated with antineutrophil cytoplasmic autoantibodies: Results of a multicenter,prospective, open‐label study of twenty‐two patients

Objective

To evaluate at 9 months and 24 months the safety and efficacy of intravenous immunoglobulins (IVIGs) administered for 6 months to treat relapses of Wegener's granulomatosis (WG) or microscopic polyangiitis (MPA) occurring either under treatment or during the year following discontinuation of corticosteroids and/or immunosuppressants.

Methods

Patients received IVIGs (0.5 gm/kg/day for 4 days) as additional therapy administered monthly for 6 months and were assessed every 3–6 months. Corticosteroids could be maintained or reintroduced at the time of relapse; immunosuppressants could be continued but could not be reintroduced. At months 9 (end point) and 24 (followup), the following information was collected: complete or partial remission, relapse as assessed with the Birmingham Vasculitis Activity Score (BVAS) 2005, and tolerance and safety of IVIG therapy.

Results

Twenty‐two Caucasian patients (7 men and 15 women) were studied: 19 had WG, and 3 had MPA. Their median age was 53 years (range 19–75 years), and their median duration of systemic vasculitis was 27 months (range 7–109 months). Their median BVAS 2005 score was 11 (range 3–25). At study entry, 21 patients were ANCA positive, and 21 patients were taking steroids and/or immunosuppressants. All patients experiencing relapse were treated with the same drug(s) plus IVIGs. All patients initially responded to IVIG therapy. By month 9, 13 patients had complete remission, 1 had partial remission, 7 had relapse, and 1 had treatment failure. In 8 of the 14 patients who had remission, the response persisted at month 24. Seven patients experienced minor side effects.

Conclusion

IVIGs induced complete remissions of relapsed ANCA‐associated vasculitides in 13 of 22 patients at month 9. Because of the good safety and tolerance profiles of IVIGs, these agents can be included in a therapeutic strategy with other drugs used to treat relapses of WG or MPA.

     

Fibrin glue in the endoscopic treatment of fistulae and anastomotic leakages of the gastrointestinal tract

Background

Fistulae or leakages of anastomotic junctions of the gastrointestinal tract used to be an indication for surgery. However, patients often are severely ill and endoscopic therapeutic options have been suggested to avoid surgical intervention.

Purpose

This is a retrospective analysis of fibrin glue application in the treatment of gastrointestinal fistulae or anastomotic leakages.

Aim

The aim of this study was to investigate the value of fibrin glue in the treatment of gastrointestinal fistulae and leakages.

Methods

From September 1996 to November 2002, 52 patients with gastrointestinal fistulae or insufficiencies have been treated endoscopically including the use of fibrin glue (Tissucol Duo S?, Baxter, Unterschleissheim, Germany). Clinical data comprising concomitant therapies and results were analysed by chart review.

Results

Twenty-six lesions were located in the oesophagus or gastroesophageal junction, 4 in the stomach, 7 in the small intestine, 13 colorectal and 2 in the pancreas. The duration of treatment ranged from 12 to 1,765?days. Two to 81?ml fibrin glue (median 8.5) was used in 1?C40 sessions (median 4). All patients received antibiotics; additional endoscopic options were frequently applied. Endoscopic therapy cured 55.7% patients (n?=?29); 36.5% (n?=?19) were cured with fibrin glue as sole endoscopic option. In 23.1% (n?=?12), surgical intervention became necessary. Patients without major infectious complications tended to have a higher cure rate without surgery (87.5% vs. 50%). Eleven patients died (21.1%).

Conclusion

Endoscopic therapy is a valuable option in the treatment of fistulae and anastomotic insufficiencies of the gastrointestinal tract. It usually is applied repeatedly. Fibrin glue is a mainstay of this procedure. Major infectious complications seem to define a subgroup of patients with poorer outcome.     

Giant-Cell Arteritis: Do We Treat Patients with Large-Vessel Involvement Differently?

Purpose

We aimed to describe the initial treatment that was used in a common hospital-based practice in patients with giant-cell arteritis with and without large-vessel involvement at diagnosis as well as the outcomes in both groups.

Factors predictive of relapse and spontaneous remission of autoimmune pancreatitis patients treated/not treated with corticosteroids

Background

Relapse and spontaneous remission (SR) are characteristic features of autoimmune pancreatitis (AIP).

Aim and methods

We conducted a study to determine if the predictive factors might be potentially related to the relapse in 70 consecutive AIP patients. Regarding SR, we studied the data of patients without corticosteroid treatment (CST).

Results

CST was administered to 60% (42/70) of the patients; however, relapse was noted in 45.2% (19/42) of these patients. In 95% (18/19) of the AIP patients developing relapse, the relapse occurred within 3?years. The relapse rate was 80% (12/15) in the AIP patients administered CST for less than 12?months and 25.9% (7/27) in those administered CST for over 12?months (p?p?p?=?0.0422) and the presence of jaundice (OR 6.945, p?=?0.0174) are significant independent factors predictive of relapse in AIP patients. SR was recognized in 65.0% (13/20) of AIP patients without CST.?The results of univariate analysis revealed that SR was associated with IgG4 seropositivity (p?p?=?0.0092) as a significant independent factor predictive of SR in these cases.

Conclusion

AIP patients with IgG4 seropositivity and jaundice are at a higher risk of relapse and they could therefore be candidates for over 3?years of maintenance CST. AIP patients with IgG4 seronegativity have a high likelihood of SR.     

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen

Purpose

The object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen.

Methods

We retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection.

Results

In the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37?C67) years. The median duration of VAC therapy was 76 (range, 53?C128) days. The median length of stay in the intensive care unit was 44 (range, 25?C127) days. The median APACHE II score was 23 (range, 18?C25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89?C92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252?C546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up.

Conclusions

Control of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.