Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery

AIM OF THE STUDY: To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. PATIENTS AND METHODS: Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. RESULTS: Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients. CONCLUSION: This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.     

Recent progress in the curative surgical treatment of stomach cancer

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.     

Genitourinary surgery and Arthur Jacobs: father of urology in Glasgow

Arthur Jacobs (1899-1974) was the father of urology in Glasgow. His extensive experience with genitourinary tuberculosis, ureterosigmoidostomy, and bladder augmentation were far ahead of his time. He became an expert in retropubic prostatectomy and was a pioneer in early imaging techniques.     

Gastric leiomyosarcoma (Review)

Gastric leiomyosarcoma is a rare malignant tumor of the stomach which has seldom been described in the literature. Three patients, aged 47, 55, and 72 at time of presentation, were treated by the authors between 1985 and 1989. Clinical and pathological findings, treatment and outcome are discussed. A literature review is provided to establish a correlation between clinical and pathological findings, surgical and oncological treatment, and rate of survival.     

Predicting effects of minimal invasive therapy

OBJECTIVE: To estimate expected effects of minimal invasive therapy (MIT). DESIGN: We developed a structured questionnaire and sent it to 35 mainly senior academic surgeons considered leaders in MIT in the UK, USA, and Canada. We asked their opinions on which specific operations would be done by minimal invasive technique and the effects of this change on hospitals over the next 5 years. We used these responses to predict effects on hospitals of MIT. We also compared predictions against published data 2 years later. RESULTS: Respondents predicted 34 specific operations would be performed using MIT, and that 53% of the patients undergoing these operations would receive MIT procedure. This transformation would lead, in their opinion, to a decline of 10 million inpatient hospital days, a 62% decline of average length of stay for operations predicted amenable to MIT, and a resultant savings of $4.5 billion in the U.S. Comparable effects could be expected to occur in other countries. CONCLUSION: Many of the trends predicted by respondents are being borne out. If these trends continue, MIT will have profound effects on patients (clinical, quality of life function), providers (hospital utilization and financing, physician training), and payers (expenditures) in all countries if respondents' predictions about MIT and its impact are even reasonable accurate. Attention should be directed first to the hospital sector, given expected effects of changes of clinical service mix, revenues, and the need for different, and differently trained, personnel.     

Health legacies from Franklin Roosevelt to Robert Dole, or how medical and health care issues took over the nation's news

Coverage of medical and health care issues has become a staple of the American press. To explain today's saturation of such coverage, I present a political continuum from reporting on the health of President Franklin Roosevelt to that of Republican presidential candidate Robert Dole. I suggest that the public can better be served by disclosures of medical records of political candidates as well as of elected officials.