Management Of Complicated Disease Research Articles

T1582: The Use of Polyflex Stents in the Management of Complicated Esophageal Diseases

Polyflex stents are removable, self-expanding, plastic stents (RSEPS) that are indicated for the treatment of malignant and benign esophageal strictures. However, they can also play an important role in the treatment of iatrogenic esophageal perforations and post-surgical anastomotic leaks by avoiding the need for surgical intervention in complicated cases. We report our experience at Georgetown University Hospital with the Polyflex esophageal stent in the treatment and management of complicated esophageal diseases.We retrospectively examined records of all pts who underwent placement of a Polyflex esophageal stent between 2004 to 2009. Patient demograhics, procedure indication, endoscopic findings, and subsequent follow-up (imaging, endoscopy and clinic) were analyzed. A successful outcome was defined as no further need for surgical or alternative endoscopic interventions and ability of the patient to tolerate oral intake. Complications were defined as chest discomfort requiring removal of the stent, stent migration, bleeding, GERD, and death.A total of 22 stents were placed in 14 pts(8 males and 6 females) with a mean age of 57 years (range, 36-83 years). Indication for stent placement were 9 for post-surgical anastomotic leak and 5 for perforations. The mean follow-up was 3 months. Stent deployment was successful in all patients. There was one patient with an unsuccessful outcome. The patient had a persistent leak despite insertion of multiple stents that required use of a fibrin sealant. However, this patient had a significant defect that was decreased by about 90% after placement of a Polyflex stent which then allowed for further treatment with the fibrin sealant. A total of 4 pts had complications following the procedure. The first patient had complicated medical issues and care was withdrawn and he subsequently died. Stent migration was noted in 3 patients. However, in these three patients the migrated stent was seen on follow-up imaging with resolution of the mucosal defect.Esophageal perforations and post-surgical anastomotic leaks can be managed endoscopically with placement of RSEPS with continued aggressive medical and endoscopic care. In our institution, this has become the initial treatment modality for complicated esophageal diseases where a team approach that includes endoscopists and thoracic surgeon is used. This practice is not only safe and effective but decreases the need for surgery, post-operative care, and length of hospital stay—all of which lead to improved patient satisfaction. In high risk surgical candidates this is an invaluable option when mortality from surgery or from lack of intervention would be inevitable.

First Report of Tomato yellow leaf curl virus Infecting Tomato, Tomatillo, and Peppers in Guatemala.

In Guatemala and other Central American countries, whitefly-transmitted geminiviruses (begomoviruses) cause economically important diseases of tomato (Solanum lycopersicum) and pepper (Capsicum annuum). Disease symptoms include stunted and distorted growth and leaf curling, crumpling, light green to yellow mosaic, purpling, and vein swelling. In Guatemala, at least eight bipartite begomovirus species infect tomato or peppers (1), but their role and relative importance is unclear. As part of an Integrated Pest Management strategy to manage these diseases, surveys for begomovirus symptoms in pepper and tomato have been conducted in the Salama Valley, Sanarate, and other locations since 2003, and begomoviruses were identified by squash blot hybridization, PCR and DNA sequencing. Beginning in 2006, a new type of symptom, stunted upright growth and upcurled leaves with yellowing of the margins and interveinal areas, was observed in tomato and tomatillo plants in the Salama Valley and Sanarate. These symptoms were similar to those induced by the exotic monopartite begomovirus Tomato yellow leaf curl virus (TYLCV). Evidence that TYLCV caused these symptoms came from positive results in high stringency squash blot hybridization tests with a TYLCV probe, and amplification of the expected size of ~0.3- and 2.8-kb fragments in PCR tests with TYLCV capsid protein (CP) gene and full-length component primer pairs, respectively (3). Sequence analyses of PCR-amplified CP fragments and portions of full-length fragments revealed 97 to 99% identity with isolates of TYLCV-Israel (TYLCV-IL). The complete nucleotide sequence of an isolate from the Salama Valley (GenBank Accession No. GU355941) was >99% identical to those of TYLCV-IL isolates from the Dominican Republic, Florida, and Cuba and ~97% identical to those of isolates from Mexico and California. Thus, this TYLCV-IL isolate (TYLCV-IL[GT:06]) was probably introduced from the Caribbean Region. To further characterize begomoviruses in the Salama Valley, leaf samples were collected from 44 and 118 tomato plants showing symptoms of begomovirus infection in March 2006 and 2007, respectively, and from 106 symptomatic pepper plants in March 2007. Begomovirus infection was confirmed in 42 of 44 and 93 of 118 of the tomato samples and 100 of 106 of the pepper samples based on PCR amplification of the expected size of ~0.6- and 1.1-kb DNA fragments with the begomovirus degenerate primers pairs AV494/AC1048 and PAL1v1978/PAR1c496, respectively (2,4). Sequence analyses of cloned PCR-amplified fragments revealed that 3 of the 44 and 16 of the 118 tomato samples collected in 2006 and 2007, respectively, and 9 of the 106 pepper samples were infected with TYLCV based on >97% identity with TYLCV-IL. In all samples, TYLCV was present in mixed infections with other begomoviruses. The introduction of TYLCV adds to the already high level of genetic complexity of bipartite begomovirus infection of tomatoes and peppers in Guatemala and will undoubtedly complicate disease management efforts.

Laparoscopic colectomy for complex diverticular disease: a justifiable choice?

Surgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease. Consecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated. A total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; p = 0.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; p < 0.0001) and surgical (28 vs. 14%; p = 0.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; p = 0.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1 day. The laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.

Class Effect of Erythropoietin Therapy on Hemoglobin A1c in a Patient with Diabetes Mellitus and Chronic Kidney Disease Not Undergoing Hemodialysis

In patients with diabetes mellitus, hemoglobin A(1c) (A1C) is commonly interpreted as a measure of long-term glycemic control, reflecting a mean glucose level over the previous 2-3 months. Although some reports suggest that treatment with recombinant erythropoietin may affect A1C values in patients undergoing hemodialysis, we know of no evidence to support this interaction in patients with chronic renal insufficiency who are not undergoing hemodialysis. In addition, we know of no evidence specific to the treatment effect of epoetin alfa and/or darbepoetin alfa on A1C. We describe a 64-year-old man with diabetes, chronic kidney disease, and anemia who was treated consecutively with epoetin alfa and darbepoetin alfa and experienced a temporal reduction in A1C level to a nadir of 4.4%. Throughout approximately 3 years of treatment with these erythropoietin analogs, the patient's total daily dose of insulin was reduced in response to his decreasing A1C values, despite elevated blood glucose levels and the absence of patient-reported hypoglycemic events. Five months after the patient's erythropoietin therapy was discontinued, his A1C value increased to 8.8%, leading us to conclude that management of the insulin dose may have been different without the falsely lowered A1C levels. Use of the Naranjo adverse drug reaction probability scale indicated a probable association between this patient's reduced A1C levels and erythropoietin therapy. This case demonstrates that both epoetin alfa and darbepoetin alfa may artificially lower A1C levels in a patient with diabetes who is not undergoing dialysis, and therefore this finding can be interpreted as a class effect. Clinicians should be aware of factors that affect A1C values, specifically erythrocyte life span. In patients receiving erythropoietin, therapeutic decisions should be based on A1C and glucose levels, as well as patient symptoms suggestive of hypo- or hyperglycemia, to avoid therapy changes that could complicate disease management.

Tetanus in developing countries: a case series and review

Few anesthesiologists have expertise in the diagnosis and treatment of tetanus, a disease that remains prevalent in developing countries. We report on a series of four cases of tetanus cases recently encountered in Rwanda. We review the clinical epidemiology, pathophysiology, diagnosis and the treatment of tetanus, and provide implications for anesthesiologists and critical care physicians. We report four cases, two involving adults who were inadequately vaccinated and experienced injuries, and two involving neonates, both of whom underwent umbilical cord transection using unsterilized equipment. All patients required tracheal intubation, and were mechanically ventilated when equipment was available. One adult and one neonate succumbed to the disease. These cases highlight the difficulties of diagnosis and management of complicated diseases in the resource-challenged health care setting of developing countries. The differential diagnosis of tetanus may be confusing, and survival depends on the rapidity of treatment with antitoxin, as well as adequate supportive care. High doses of sedatives and muscle relaxants, as well as prolonged mechanical ventilation, are usually necessary. Mortality remains high, usually resulting from late respiratory failure and cardiovascular collapse, associated with autonomic instability. Anesthesiologists and critical care physicians have an important role to play in the management of these patients. Increased involvement in humanitarian health organizations, immigration from developing countries, and emergence of high risk groups in developed countries will likely result in more exposure of anesthesiologists to the complexities of this disease.

Use of Hartmann’s procedure in England

Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate. Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's. Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25). This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.

Surgical management of complicated ulcer disease

The advent of excellent acid-suppressing medications and the not-so-recent realization of the importance of Helicobacter pylori have markedly altered the physician's management of ulcer-related problems. Although the investigation of acid-peptic disorders helped to launch the modern understanding of abdominal surgery, the majority of operative interventions are now aimed at managing emergent problems that arise from ulcers. There are a waning number of surgeons with extensive experience in the operations that will be described in this report. The global management of patients who suffer from ulcer-related problems will require close cooperation among and between specialties, as well as clear understanding of our respective capabilities and limitations.

Tuberculosis, a neglected opportunity?

Historically, tuberculosis (TB) has fallen firmly in the group of ‘neglected diseases’—diseases in which pharmaceutical companies have been reluctant to invest due to a perception of low commercial potential. According to the World Health Organization (WHO), an estimated 1.7 million deaths resulted in 2004 from TB, and the global prevalence of TB was 14.6 million1. However, more than 80% of people with TB live in sub-Saharan Africa or Asia2, where spending on healthcare is low and access to drugs is limited. Owing to the low commercial interest in treating TB, no new drug class has been introduced for over 30 years. The current market is dominated by generic products. Relatively few international drug manufacturers market TB therapies; exceptions are Sanofi-Aventis, Pfizer and Sandoz (Novartis’s generics division). However, over the past 10–15 years, several factors have emerged, which are contributing to increased research and development (R&D) activity in TB treatment. The prevalence of TB grew significantly in the late 1980s and 1990s, driven by cases in sub-Saharan Africa, but also by a resurgence in both the US and Europe, where TB had been considered an eradicated disease. The WHO identified TB as a global health emergency in 1993 and launched the Global Plan to Stop TB, which focused on early TB diagnosis and reliable access to treatment. In areas of high HIV prevalence, coinfection with TB and HIV has become a critical issue, fuelling the increase in TB cases. Coinfection not only increases the proportion of individuals with TB who develop active disease, but also presents treatment challenges owing to interactions between TB and HIV drugs. Increased incidence of multidrug-resistant TB (MDR-TB) has further complicated effective disease management and created a demand for new treatments that are effective against resistant disease strains. The Global TB Alliance, a nonprofit organization working with public and private sectors to accelerate R&D in TB, was established in 2000. The TB Alliance has raised substantial funding for clinical research and is now the leading developer of new TB drugs, with agents in all phases of development. Nonprofit investment has been a key factor in stimulating interest in TB R&D within the pharmaceutical industry. Most products in the TB pipeline are joint projects between private and nonprofit organizations. The TB Alliance received donations of $39 million and $14 million from the Dutch and Irish governments, respectively3,4. In addition, the Bill & Melinda Gates Foundation provided grants of $25 million in 2000 and a further $104 million in 2006 (ref. 5).

Treatment of an Adult Patient with Hemophilia A and High Titer Inhibitor with Rituximab and Prednisone.

Development of inhibitors is a serious complication in hemophilia A patients (factor VIII deficiency) who receive plasma-derived or recombinant products. It occurs in about 20–30% of patients with severe or moderate hemophilia A. The presence of a high titer inhibitor (titer > 5BU), is associated with increased morbidity and mortality, complicates disease management, and increases cost of treatment. Treatments used for the management of acute bleeds include high doses of human FVIII, porcine FVIII, prothrombin complex concentrates, FVIII bypassing activity (FEIBA), and recombinant VIIa (rVIIa)). The induction of immune tolerance (IT)with daily high doses of FVIII has been reported to eradicate the inhibitor in 60–80% of patients; although it is a very costly procedure, the response appears to be dependent on the level of the inhibitor with patients with low inhibitor titer (<10 BU) responding better to IT treatment. To rapidly reduce/eradicate the alloimmune factor VIII antibodies immunomodulatory agents, including immunoglobulin, corticosteroids, cyclophosphamide, azathioprine, and plasmapheresis have been used. Rituximab, an anti-CD20 monoclonal antibody, eliminates circulating B cells and has been shown to reduce/eradicate alloimmune factor VIII antibodies in children with severe hemophilia A. We report the clinical course and response to rituximab treatment in a 24 year old male with moderate hemophilia A and high titer inhibitor. The patient presented with a massive retroperitoneal bleed with Hb 6.4g/dL and an inhibitor titer of 41 BU reaching a maximum of 111 BU over the next four weeks. For the acute bleeding episode, he received FEIBA and rVIIa. For the treatment of inhibitor, he was given rituximab 375 mg/m2 × 4 together with prednisone 1 mg/Kg daily. Prednisone was slowly tapered off over the next several weeks. Three months later, his inhibitor titer had decreased to 35 BU and remained below 15 BU for the next 30 weeks. The course of this patient's response suggests that rituximab in combination with prednisone may rapidly reduce inhibitor titer in adult patients with hemophilia and high titer inhibitor. It is possible the rituximab therapy may replace IT therapy or be used as an adjunct to IT therapy. Also, the combination of rituximab and prednisone treatment may reduce/prevent the exposure of young patients to cytotoxic chemotherapy. Randomized clinical trials will be required to determine whether the combination of rituximab and prednisone is a better option compared to cytoxan and prednisone to reduce/eradicate inhibitors in young adult hemophilia patients with high titer inhibitor. [Display omitted]

Laparoscopic Management of Acid Peptic Disease

Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. Almost all types of conventional operations available for ulcer disease have been successfully performed by the laparoscopic approach and this has become the preferred approach in tertiary centers for operative management of acid peptic disease. Between 1995 and 2004, laparoscopic management was offered to refractory or obstructive acid peptic disease patients. For intractable disease, we performed either posterior truncal vagotomy with anterior fundal seromyotomy or posterior truncal vagotomy with anterior proximal gastric vagotomy. For peptic ulcer disease complicated with gastric outlet obstruction, we carried out bilateral truncal vagotomy with gastrojejunostomy. Two hundred sixty three patients were operated of whom 236 (89.7%) were men and the average age of the patients was 48.4 years. Thirty-two (12.2%) patients underwent posterior truncal vagotomy with anterior seromyotomy, 89 (33.8%) underwent posterior truncal vagotomy with anterior proximal gastric vagotomy, 120 (45.6%) underwent bilateral truncal vagotomy with stapled gastrojejunostomy whereas 22 (8.4%) underwent bilateral truncal vagotomy with hand-sewn gastrojejunostomy. The average operating times were 142, 110, 98, and 72 minutes, respectively. The average postoperative stay was 5.4 days. Laparoscopic posterior truncal vagotomy with anterior proximal gastric vagotomy for refractory disease and laparoscopic bilateral truncal vagotomy with stapled gastrojejunotstomy for obstructive disease have become the standard at our institution. Regardless of the preference of individual surgeon, our results have shown that laparoscopic surgery may become the gold standard for surgical management of peptic ulcer disease.

Management of Complicated Peptic Ulcer Disease

Management of Complicated Peptic Ulcer Disease

Management of Complicated Peptic Ulcer Disease—Reply

Management of Complicated Peptic Ulcer Disease—Reply

Management of Complicated Peptic Ulcer Disease

Our understanding of the pathophysiological features of peptic ulcer disease has rapidly evolved during the last century. Early understanding of gastric physiologic characteristics led to logical and time-tested surgical procedures aimed at acid reduction and a lowering of ulcer recurrence rates. A dramatic shift in treatment occurred with the recognition and growing knowledge of Helicobacter pylori (HP). Where once surgery dominated therapy for ulcer diathesis, medical therapy has now superseded. Just as gastric resection seemed radical to Dr Mayo, thus was medical treatment of peptic ulcer disease similarly approached with skepticism. What was the balance of medical and surgical management of peptic ulcer disease as we entered the 21st century? Complications of peptic ulcer disease requiring operative intervention have remained important. However, the absolute number of procedures performed has significantly diminished in recent years. 1 The reason for the decrease in surgical intervention, both emergent and elective, is multifactorial. Improvements in therapeutic endoscopy, the introduction of effective antacid therapy, and the recognition and treatment of HP infection have all greatly contributed to the successful nonoperative treatment of patients with peptic ulcer disease. 2-5 With respect to complicated ulcer disease, treatment and eradication of HP infection have arguably led to a shift from treating patients operatively to treating them nonoperatively. This changing management scheme has occurred despite a relative paucity of data regarding the incidence and contribution of HP infection to the etiology of complicated peptic ulcers. Indeed, reports in the literature regarding the incidence of HP infection in a surgical cohort have been sparse. From a surgeon's perspective, data relative to HP infection and the classic indications for surgery-perforation, bleeding, and gastric outlet obstruction (GOO)- have until recently been largely inferential based on treatment of those with uncomplicated peptic ulcers. Deviation from traditional surgical management might prove detrimental should other nonoperative modalities be used. The purpose of this discussion is to review the known pathophysiological features of peptic ulcer disease with a focus on those complications encountered by the surgeon.

Quality of life in chronic disease rehabilitation

In 2002 the World Health Organisation (WHO) reported that worldwide, deaths due to chronic diseases were accountable for around 30 million people. An earlier report by the WHO revealed that the leading causes of deaths due to chronic disease were cardiovascular disease (17 million), cancers (7 million), chronic lung diseases (4 million) and diabetes (approximately 1 million). In developed nations, the most frequently reported risk factors associated with chronic diseases are exposure to tobacco products (12.2%), hypertension (10.9%), alcohol consumption (9.2%), elevated cholesterol (7.6%), and obesity (7.4%), unhealthy diets that include high saturated fat and sugar content (3.9%) and sedentary lifestyle (3.3%). In view of the demographic shifts, and the strong association with aging and chronic disease, it is estimated that worldwide, within the next two decades, the predicted number of deaths due to chronic illness will rise to around 50 million people per year. Amongst elderly populations in particular, circulatory diseases, respiratory diseases, mental health problems, and musculoskeletal diseases are frequently cited as causes of chronic illness. Population estimates in the UK suggest that around 70% of people by the age of 80 report some type of health-related disability. Patients with chronic conditions will often have multiple co-morbidities with complicated disease management which will necessitate considerable contributions from their caregivers. The caregivers of the chronically ill are often unpaid family members who are frequently placed under considerable stress, and as a result can themselves suffer from functional decline, depression, isolation and loneliness.

Nonoperative Management of Complicated Diverticular Disease

The complications of diverticular disease of the colon can be divided into those related to inflammatory conditions (diverticular abscess, fistula, and perforation) and those related to noninflammatory conditions (lower gastrointestinal hemorrhage and noninflammatory stricture or obstruction). Nonoperative management of uncomplicated diverticulitis includes bowel rest and antibiotics. For abscesses, percutaneous drainage by radiologic guidance often turns complicated diverticulitis to an uncomplicated condition. In very select instances, fistulas or even perforation may be managed without operation. Strictures may be dilated or stented. Diverticular hemorrhage may be controlled with colonoscopic and angiographic techniques. For colonoscopy, these include cautery, epinephrine injection, and endoclips. For angiography, these include arterial infusion of vasopressin and selective embolization of bleeding vessels. For both diverticulitis and diverticular bleeding, these nonoperative therapeutic modalities may be utilized as a bridge to surgery, or in select instances as a definitive therapy obviating the need for surgery.

Use of the 70-degree diamond burr in the management of complicated frontal sinus disease.

Management of frontal sinus disease may require drill-out of bone in the frontal recess for access, ventilation, and drainage of the sinus cavity; removal of osteitic foci; or resection of neoplastic tissue. Technological advances, particularly burrs with angles of 70 degrees and stereotactic navigational imaging, offer new opportunities to provide access and minimize trauma. The preliminary study evaluates the safety and efficacy of such minimally invasive approaches. Retrospective review. The authors describe the use of a 70-degree diamond burr in a series of 10 patients with complicated frontal sinus disease who underwent endoscopic frontal sinusotomy under stereotactic imaging guidance. The diagnoses consisted of frontal sinus mucocele (n = 4), chronic frontal sinusitis (n = 1), Pott's puffy tumor after frontoethmoid fracture (n = 1), and recurrent inverting papilloma (n = 4). Partial septectomy was required in 6 of 10 patients. No complications were attributable to the drill-out procedure, despite a pre-existing frontoethmoid bony dehiscence in 6 of 10 patients. One patient had a CSF leak during removal of tumor from the skull base. One patient required revision frontal sinusotomy 10 months after the initial procedure, and another required further surgery for residual inverting papilloma on the medial orbital wall. All frontal sinusotomies were patent at last follow-up (mean period, 9.3 mo). Extended endoscopic frontal sinusotomy may be necessary in the management of complicated frontal sinus inflammatory disease and inverting papilloma. The 70-degree diamond burr is a safe and effective tool for access to the frontal recess. Complication rates appear to be similar to those for other extended frontal sinusotomy approaches.

Surgical Management of Complicated Hydatid Disease of the Liver

Increased worldwide travel and immigration have led to an increase in the incidence of hepatic hydatid disease outside of endemic areas. In nonendemic areas lack of familiarity with the disease may lead to a delay in diagnosis with increased risk for development of complicated disease. Complicated disease is defined as: infected cysts, cysts with a hyperechoic solid pattern or calcified walls, or cysts with biliary rupture. Over a 6-month period six patients with complicated hydatid disease were referred to our institution. All six patients were immigrants from endemic areas and were found to have complicated hepatic hydatid disease including cholangitis and intrabiliary rupture. Patients were treated with oral albendazole for 3 weeks before operation and oral praziquantel for 2 days preoperatively. Surgical therapy consisted of subtotal cystectomy, cholecystectomy in all patients, and cystic duct biliary decompression-drainage in five patients. The one patient without biliary drainage developed a postoperative bile leak that resolved with endoscopic biliary stenting. All patients received albendazole for 3 months postoperatively and were free of disease at 6 to 24 months follow-up. We conclude that although nonoperative management with percutaneous drainage or medical management alone may be successful in patients with uncomplicated disease operation remains the therapy of choice for complicated hydatid disease.

A Conjugate Vaccine for the Prevention of Pediatric Pneumococcal Disease

The use of the pneumococcal 7-valent conjugate vaccine (PCV7 [Prevnar], Wyeth Lederle Vaccines), and the impact it is likely to have on pneumococcal disease are reviewed. Pneumococcal disease in infants and young children is a major health care burden, and the increase in antibiotic resistance among pneumococci has complicated disease management. The 23-valent polysaccharide pneumococcal vaccines do not protect infants and children younger than 2 years of age. PCV7 is effective in this population and should dramatically reduce the incidence of invasive pneumococcal disease and have an impact on the incidence of infections caused by Streptococcus pneumoniae serotypes present in the vaccine. Research has shown that pneumococcal conjugate vaccines reduce nasopharyngeal carriage of vaccine serotype S. pneumoniae, including antibiotic-resistant strains. Routine immunization is expected to substantially reduce the morbidity and mortality associated with invasive pneumococcal disease in children, and coupled with expected herd immunity and decreased antibiotic selective pressure, it should have a positive impact beyond the immunized population.

Complicated pancreatic disease management--radiologist/interventionist batting cleanup?

Abstract The long term results of various interventional procedures used in the treatment of patients with chronic pancreatic fistulas or severe pancreatic pain syndrome, after failure of both surgery and endoscopic catheterization, are described. Five patients were divided into two groups. Group 1 contained three patients with recurrent severe abdominal pain with superimposed episodes of acute pancreatitis. Two patients had undergone prior Whipple procedures but remained symptomatic. The third had a 6-yr history of alcoholic pancreatitis. All three had failed selective pancreatic endoscopy because of a proximal pancreatic duct stricture. The pancreatic duct was dilated to between 7 and 10 mm by CT or ultrasound imaging. Group 2 patients had pancreaticocutaneous fistulas that developed after surgical and percutaneous pseudocyst drainage. Both patients’ fistulas had been unresponsive to therapy with somatostatin analogues, and had been controlled by means of percutaneous drains. Patients were treated under either general anesthesia (two patients, patient preference) or conscious sedation. Each received preprocedure antibiotics and had normal coagulation profiles. Oral contrast was given to opacify the colon the night before the procedure. Ultrasound or fluoroscopic guidance was used to puncture the pancreatic duct, either directly or through the stomach (after placement of T fasteners). The procedures were then individualized to fit the particular pathology and anatomical situation. At least one procedure required endoscopic assistance (rendezvous procedure) for guidewire stabilization to deliver an angioplasty catheter across a pancreatic duct stricture. The criteria for successful treatment included partial or complete relief of abdominal pain, with normalization of pancreatic duct caliber in group 1 and cure of the pancreatic fistulas in group 2 without recurrent episodes of pancreatitis. All three patients in group 1 had prompt relief of abdominal pain after placement of percutaneous pancreatic duct drains. All had return to normal caliber of the pancreatic duct by imaging. One patient had a recurrent episode of abdominal pain after drain removal, but this was found to be due to a ureteral stricture. The details of the procedures for treating the fistulas have been previously reported (1) . Cope and colleagues’ report assesses long term efficacy of these interventions. Both patients with fistulas were cured out to 5-yr follow-up after removal of their drains. None of these percutaneous procedures showed early complications such as leakage of pancreatic juice, sepsis, hemorrhage, or acute pancreatitis, as determined symptomatically by hematological screening and abdominal imaging. The authors conclude that percutaneous pancreatic duct drainage and stent placement is safe in selected cases. It is particularly useful when endoscopic stent placement is unsuccessful and surgery too risky. They also suggest several other situations in which this technique may be beneficial.

Complicated pancreatic disease management—radiologist/interventionist batting cleanup?

The long term results of various interventional procedures used in the treatment of patients with chronic pancreatic fistulas or severe pancreatic pain syndrome, after failure of both surgery and endoscopic catheterization, are described. Five patients were divided into two groups. Group 1 contained three patients with recurrent severe abdominal pain with superimposed episodes of acute pancreatitis. Two patients had undergone prior Whipple procedures but remained symptomatic. The third had a 6-yr history of alcoholic pancreatitis. All three had failed selective pancreatic endoscopy because of a proximal pancreatic duct stricture. The pancreatic duct was dilated to between 7 and 10 mm by CT or ultrasound imaging. Group 2 patients had pancreaticocutaneous fistulas that developed after surgical and percutaneous pseudocyst drainage. Both patients’ fistulas had been unresponsive to therapy with somatostatin analogues, and had been controlled by means of percutaneous drains. Patients were treated under either general anesthesia (two patients, patient preference) or conscious sedation. Each received preprocedure antibiotics and had normal coagulation profiles. Oral contrast was given to opacify the colon the night before the procedure. Ultrasound or fluoroscopic guidance was used to puncture the pancreatic duct, either directly or through the stomach (after placement of T fasteners). The procedures were then individualized to fit the particular pathology and anatomical situation. At least one procedure required endoscopic assistance (rendezvous procedure) for guidewire stabilization to deliver an angioplasty catheter across a pancreatic duct stricture. The criteria for successful treatment included partial or complete relief of abdominal pain, with normalization of pancreatic duct caliber in group 1 and cure of the pancreatic fistulas in group 2 without recurrent episodes of pancreatitis. All three patients in group 1 had prompt relief of abdominal pain after placement of percutaneous pancreatic duct drains. All had return to normal caliber of the pancreatic duct by imaging. One patient had a recurrent episode of abdominal pain after drain removal, but this was found to be due to a ureteral stricture. The details of the procedures for treating the fistulas have been previously reported (1). Cope and colleagues’ report assesses long term efficacy of these interventions. Both patients with fistulas were cured out to 5-yr follow-up after removal of their drains. None of these percutaneous procedures showed early complications such as leakage of pancreatic juice, sepsis, hemorrhage, or acute pancreatitis, as determined symptomatically by hematological screening and abdominal imaging. The authors conclude that percutaneous pancreatic duct drainage and stent placement is safe in selected cases. It is particularly useful when endoscopic stent placement is unsuccessful and surgery too risky. They also suggest several other situations in which this technique may be beneficial.