Surgical Management of Pancreaticopleural Fistulas

Background: Pancreaticopleural fistula is defined as a communication between the pancreatic duct and the pleural cavity. Initially, it is treated conservatively and endoscopically. Surgery is performed within a small group of patients in whom other therapeutic approaches failed.

Patients and methods: In this retrospective study, nine patients with pancreaticopleural fistulas were treated. In 8 of nine patients, conservative treatment was used experimentally. Patients were considered as having a pancreaticopleural fistula before operation if a fistulous tract was seen on radiologic examination or if a large exudative pleural effusion was present with an amylase level > 5.000 U/L and total pleural fluid protein content > 3 g/L. All patients were evaluated for computed tomography (CT), ultrasonography (USG) examination and endoscopic retrograde cholangiopancreatography (ERCP).

Results: The mean age of patients was 47 (35–51) years. Pancreatic effusion was present in the left pleural cavity in 6 cases, in the right cavity in 2 and on both sides in 1 case. The causes of fistula formation were as follows: chronic pancreatitis due to alcohol abuse-seven patients, rupture of the pancreas and main pancreatic duct due to trauma-one patient and pancreatolithiasis-1 patient. Endoscopic stenting of the main pancreatic duct was unsuccessful in all patients except one. Five patients underwent distal (n = 4) or corporocaudal pancreatectomy (n = 1) with splenectomy, two underwent pancreatic duct anastomosis with an intestinal loop (the Partington-Rochelle procedure) and one underwent pancreaticoduodenectomy. Postoperative complications were observed in two patients. There were no cases of hospital mortality. The mean time of hospitalization was 16 days. Seven patients reported for the follow-up examination in the postoperative period of 10 to 67 months. No recurrence of pleural effusion was noted in any case. Conclusion: Surgical treatment is effective and safe for the management of a pancreaticopleural fistula when conservative and endoscopic therapy has failed.     

A nickel–titanium memory-shape device for gastrojejunostomy: comparison of the compression anastomosis clip and a hand-sewn anastomosis

Background

The aim of this study was to evaluate the efficacy of a compression anastomosis clip (CAC) for gastrojejunostomy and comparison of a novel technique with a hand-sewn anastomosis.

Methods

Sixty-six patients underwent gastrojejunostomy with the CAC or hand-sewn anastomosis. The time of bowel function recovery, the duration of nasogastric drainage, the time of initiation of oral feeding, the duration of postoperative hospital stay, the time needed to expel the clip, and the observation of any complications were recorded.

Results

Neither group had anastomotic complications such as leakage or obstruction. Anastomosis time was shorter in the CAC group than in the control group (P < 0.01). The mean time of clip expulsion was 15.1 ± 6.04 d. There was no statistical difference in postoperative results between the two groups. There was a moderate positive correlation between the day of first bowel movement and the day of clip expulsion (r = 0.536) and a strong correlation between the duration of nasogastric drainage and the day of clip expulsion (r = 0.881).

Conclusions

The method of using a CAC appeared to be safe, easy, inexpensive, and less time consuming. It should be taken into consideration that intra-abdominal complications may cause delayed CAC expulsion.     

Genetic diversity of hepatitis C virus quasispecies in chronic renal failure patients in Midwest Brazil

Hepatitis C virus (HCV) quasispecies constitute a dynamic population in a continuous process of variation and selection. To investigate effect of the immune system on the genetic variability of HCV, we compared the hypervariable region 1 (HVR1) of immunosuppressed patients with chronic renal failure (CRF group) to immunocompetent patients with HCV chronic infection (control group). The HVR1 from ten samples of each group was amplified, cloned and sequenced. The HCV quasispecies from the control group had a higher frequency of variable sites in HVR1 (83.9 % vs 59.3 %, p < 0.05), as well as a greater diversity within (intra-patient) and between samples, compared to the CRF group. The clustering of the majority of the quasispecies of the CRF group in the phylogenetic tree also showed the limited diversity of the quasispecies in immunosuppressed patients. Moreover, a higher variability of amino acids at positions 384, 386, 391, 394, 397, 398, 400, 405 and 410 was observed in the control group than in the CRF group, which showed a greater variability only at position 388 (p < 0.05). These data corroborates the hypothesis that the major selective pressure factor is the immune system, which promotes a high degree of diversity in the viral progeny and contributes to a constant evolution of HCV.     

The Biology of Veganism: Plasma Metabolomics Analysis Reveals Distinct Profiles of Vegans and Non-Vegetarians in the Adventist Health Study-2 Cohort

It is unclear how vegetarian dietary patterns influence plasma metabolites involved in biological processes regulating chronic diseases. We sought to identify plasma metabolic profiles distinguishing vegans (avoiding meat, eggs, dairy) from non-vegetarians (consuming ≥28 g/day red meat) of the Adventist Health Study-2 cohort using global metabolomics profiling with ultra-performance liquid chromatography mass spectrometry (UPLC-MS/MS). Differences in abundance of metabolites or biochemical subclasses were analyzed using linear regression models, adjusting for surrogate and confounding variables, with cross-validation to simulate results from an independent sample. Random forest was used as a learning tool for classification, and principal component analysis was used to identify clusters of related metabolites. Differences in covariate-adjusted metabolite abundance were identified in over 60% of metabolites (586/930), after adjustment for false discovery. The vast majority of differentially abundant metabolites or metabolite subclasses showed lower abundance in vegans, including xanthine, histidine, branched fatty acids, acetylated peptides, ceramides, and long-chain acylcarnitines, among others. Many of these metabolite subclasses have roles in insulin dysregulation, cardiometabolic phenotypes, and inflammation. Analysis of metabolic profiles in vegans and non-vegetarians revealed vast differences in these two dietary groups, reflecting differences in consumption of animal and plant products. These metabolites serve as biomarkers of food intake, many with potential pathophysiological consequences for cardiometabolic diseases.     

Sensibilisierungstrainings gegenüber häuslicher Gewalt für medizinisches Fachpersonal. Sind diese auch effizient?

Untersuchungen der Europäischen Union folgend, sind 33 % aller Frauen ab dem 15. Lebensjahr von häuslicher Gewalt betroffen und wenden sich bei der Suche nach Hilfe vorwiegend an das Gesundheitssystem. Das Erleben von Gewalt hat schwerwiegende Folgen nicht nur auf die psychische, sondern auch auf die körperliche Gesundheit der Betroffenen. So kommt es neben Verletzungsfolgen, u. a. zu unerklärbaren Schmerzen, gastrointestinalen Beschwerden oder Problemen im Bereich der reproduktiven Medizin. Nachdem sich viele der Betroffenen auf der Suche nach Unterstützung zuerst an das Gesundheitssystem wenden, kommt dem medizinischen Fachpersonal auch hier eine Schlüsselrolle zu, wodurch Sensibilisierungstrainings für die Berufsgruppen immer bedeutender werden. Teilnehmerinnen und Teilnehmer an Sensibilisierungstrainings gegenüber häuslicher Gewalt wurden vor und nach dem Training mit Hilfe eines Fragebogens zu ihrer empfundenen Sicherheit im Umgang mit von Gewalt betroffenen Patientinnen und Patienten befragt. Die Evaluation eines Schulungszyklus am Landeskrankenhaus Innsbruck zeigte signifikante Verbesserungen im subjektiven Sicherheitsgefühl im Umgang mit gewaltbetroffenen Patientinnen und Patienten. Ein strukturierter Aufbau der Sensibilisierungstrainings mit Basiskursen und Aufbauseminaren, sowie einem Fokus auf Beziehungsaufbau und Umgang mit Emotionen erscheint sinnvoll.