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Introduction: Concrements of the common bile duct (choledocholithiasis) occur from 8% to 20% in patients with acute cholecystitis. This pathology requires simultaneous correction of the pathology of the gallbladder and the common bile duct. Methods: We retrospectively analyzed the case histories of 135 patients who underwent endoscopic retrograde cholangio pancreatography, endoscopic papillosphincterotomy, choledocholithoextraction followed by laparoscopic cholecystectomy + CHEST + LCE) for acute cholecystitis in combination with choledocholithiasis in the period from January 2016 to March 2021. Patients who underwent simultaneous treatment (ERCP + EPST + CLE + LCE under one anesthesia) were assigned to the OS group (n = 63), patients who underwent two-stage treatment (ERCP + EPST + CLE and LCE on the 3-4th day during one hospitalization) were assigned to the TS group (n = 72). All endoscopic procedures in both groups were performed by the same endoscopist using the same technique. Result: There were significant differences between the groups in terms of the duration of anesthesia, the dynamics of the decrease in the blood serum of the total bilirubin and the leukocytes range at the postoperative period, the frequency of postoperative complications and the duration of the average hospitalization in favor of one-stage treatment.

Background / objective. Laparoscopic cholecystectomy is a safe procedure and the treatment of choice for acute cholecystitis. As an alternative treatment option in critically ill patients percutaneous cholecystostomy (PC) is performed.Methods. Retrospective review of patients who had undergone PC from 2008 to 2017 at the Department of Surgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics. Patients were reviewed for demographic features, laboratory tests, ASA class, complications, outcomes, hospital stay and mortality rate.Results. Fifty-four patients were included in the study. Forty patients (74%) were ASA III and ten patients (18.5%) – ASA IV. Statistically signi­ficant decrease in white blood cell count (from 14.26±6.61 to 8.65±5.15) and C-reactive protein level (from 226.22±106.60 to 51.91±63.70) following PC was observed. The median hospital stay was 13.06 (range 2–68) days and 30-day mortality rate 13%. There were no deaths directly related to procedure. For eleven patients (20.4%) delayed cholecystectomy was scheduled.Conclusions. PC is a reasonable treatment option for high-risk patients with acute cholecystitis and co-morbidities. It can be used as a temporizing treatment option or as a definitive treatment with a low number of delayed cholecystectomies.

Background: Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis. Methods: We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients. Results: Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after “clinically successful” treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10–20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%. Conclusions: The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.

BACKGROUND AND OBJECTIVES: Chronic pancreatitis (CP) is a debilitating fibro-inflammatory disease with a profound impact on patients' quality of life (QOL). We investigated determinants of QOL in a large cohort of CP patients.METHODS: This was a multicentre study including 517 patients with CP. All patients fulfilled the EORTC QLQ-C30 questionnaire. Questionnaire responses were compared to results obtained from a general reference population (n = 11,343). Demographic characteristics, risk factors (smoking and alcohol consumption), pain symptoms, disease phenotype (complications) and treatments were recorded. A multivariable regression model was used to identify factors independently associated with QOL scores.RESULTS: Included patients had a mean age of 56.3 ± 12.8 years, 355 (69%) were men and 309 (60%) had alcohol aetiology. Compared to the reference population, patients with CP had lower global health status (50.5 vs. 66.1; p < 0.001) as well as reduced scores for all functional scales (all p < 0.001). Additionally, CP patients reported a higher burden for all symptom items, with pain being the most prominent complaint (all p < 0.001). Constant pain (coefficient -11.3; p = 0.02), opioid based pain treatment (coefficient -19.7; p < 0.001) and alcoholic aetiology (coefficient -5.1; p = 0.03) were independently associated with lowered global health status. The final multivariable model explained 18% of the variance in global health status.CONCLUSIONS: Patients with CP have significantly lower QOL compared to a population-based reference population. Factors independently associated with a lowered QOL are constant pain, opioid based pain treatment and alcohol aetiology. However, these factors only explain a fraction of QOL and additional factors need identification.

Background and objective This study deals with an important issue of setting the role and value of the dynamic computed tomography (CT) perfusion analysis in diagnosing pancreatic ductal adenocarcinoma (PDAC). The study aimed to assess the efficacy of perfusion CT in identifying PDAC, even isodense or hardly depicted in conventional multidetector computed tomography. Methods A total of 56 patients with PDAC and 56 control group patients were evaluated in this study. A local perfusion assessment, involving the main perfusion parameters, was evaluated for all the patients. Sensitivity, specificity, positive, and negative predictive values for each perfusion CT parameter were defined using cutoff values calculated using receiver operating characteristic curve analysis. We accomplished logistic regression to identify the probability of PDAC. Results Blood flow (BF) and blood volume (BV) values were significant independent diagnostic criteria for the presence of PDAC. If both values exceed the determined cutoff point, the estimated probability for the presence of PDAC was 97.69%. Conclusions Basic CT perfusion parameters are valuable in providing the radiological diagnosis of PDAC. The estimated BF and BV parameters may serve as independent diagnostic criteria predicting the probability of PDAC.

Background/aim Apoptotic peptidase activating factor 1 (APAF-1) is essential regulator of apoptosis and inactivation by DNA methylation is common event in numerous cancer types. We investigated the regulation of APAF-1 through DNA methylation in pancreatic cancer. Materials and methods Datasets from 44 patients after pancreatoduodenectomy and the pancreatic adenocarcinoma (PDAC) cell lines Capan-2 and MIA PaCa-2 treated with decitabine were analyzed by RT-PCR, immunoblotting, methylation-specific PCR analysis, apoptosis and viability assays to identify effects of APAF-1 regulation. Results APAF-1 mRNA and protein levels were significantly down-regulated, and APAF-1 methylation status was associated with perineural invasion in PDAC. Decitabine inhibited cell viability and increased apoptosis rates, however failed to restore APAF-1 mRNA and protein levels in cells. Conclusion APAF-1 gene hypermethylation may contribute to the progression of PDAC through perineural invasion. Decitabine could sensitize pancreatic cancer cells to apoptosis and growth retardation, however, not directly through the APAF-1 demethylation process.

BACKGROUND: Diabetes mellitus is a common complication of chronic pancreatitis. It is traditionally considered to develop as a consequence of beta cell loss, but there might be additional factors. Recent studies have highlighted the importance of type 2 diabetes-related risk factors in this context and population-based studies show increased risk of diabetes following acute pancreatitis. The aim of this study was to explore multiple risk factors for diabetes in patients with chronic pancreatitis.METHODS: We conducted a multicentre, cross-sectional study of patients with definitive chronic pancreatitis according to the M-ANNHEIM criteria. We used multivariable logistic regression models to determine risk factors independently associated with diabetes.RESULTS: The study included 1117 patients of whom 457 (40.9 %) had diabetes. The mean age was 52.8 ± 14.2 years and 67% were men. On multivariate analysis, parameters indicative of beta cell loss (pancreatic calcification, exocrine insufficiency, pancreatic resection) were confirmed as independent risk factors for diabetes (all p ≤ 0.02). In addition, type 2 diabetes-related risk factors (dyslipidaemia and overweight/obesity) were associated with the presence of diabetes (all p ≤ 0.002). Patients with a history of pancreatic fluid collections (indicative of previous attacks of acute pancreatitis) had a marginally increased risk of diabetes (p = 0.07).CONCLUSION: In patients with chronic pancreatitis the presence of diabetes is associated with multiple risk factors including type 2 diabetes-related factors. Our observations attest to the understanding of this entity and may have implications for treatment.

Background: Acid suppressing drugs (ASD) are generally used in acute pancreatitis (AP); however, large cohorts are not available to understand their efficiency and safety. Therefore, our aims were to evaluate the association between the administration of ASDs, the outcome of AP, the frequency of gastrointestinal (GI) bleeding and GI infection in patients with AP. Methods: We initiated an international survey and performed retrospective data analysis on AP patients hospitalized between January 2013 and December 2018. Results: Data of 17,422 adult patients with AP were collected from 59 centers of 23 countries. We found that 23.3% of patients received ASDs before and 86.6% during the course of AP. ASDs were prescribed to 57.6% of patients at discharge. ASD administration was associated with more severe AP and higher mortality. GI bleeding was reported in 4.7% of patients, and it was associated with pancreatitis severity, mortality and ASD therapy. Stool culture test was performed in 6.3% of the patients with 28.4% positive results. Clostridium difficile was the cause of GI infection in 60.5% of cases. Among the patients with GI infections, 28.9% received ASDs, whereas 24.1% were without any acid suppression treatment. GI infection was associated with more severe pancreatitis and higher mortality. Conclusions: Although ASD therapy is widely used, it is unlikely to have beneficial effects either on the outcome of AP or on the prevention of GI bleeding during AP. Therefore, ASD therapy should be substantially decreased in the therapeutic management of AP. (C) 2020 IAP and EPC. Published by Elsevier B.V.

Objective To test the degree of agreement in selecting therapeutic options for patients suffering from colorectal liver metastasis (CRLM) among surgical experts around the globe. Summary/background Only few areas in medicine have seen so many novel therapeutic options over the past decades as for liver tumors. Significant variations may therefore exist regarding the choices of treatment, even among experts, which may confuse both the medical community and patients. Methods Ten cases of CRLM with different levels of complexity were presented to 43 expert liver surgeons from 23 countries and 4 continents. Experts were defined as experienced surgeons with academic contributions to the field of liver tumors. Experts provided information on their medical education and current practice in liver surgery and transplantation. Using an online platform, they chose their strategy in treating each case from defined multiple choices with added comments. Inter-rater agreement among experts and cases was calculated using free-marginal multirater kappa methodology. A similar, but adjusted survey was presented to 60 general surgeons from Asia, Europe, and North America to test their attitude in treating or referring complex patients to expert centers. Results Thirty-eight (88%) experts completed the evaluation. Most of them are in leading positions (92%) with a median clinical experience of 25 years. Agreement on therapeutic strategies among them was none to minimal in more than half of the cases with kappa varying from 0.00 to 0.39. Many general surgeons may not refer the complex cases to expert centers, including in Europe, where they also engage in complex liver surgeries. Conclusions Considerable inconsistencies of decision-making exist among expert surgeons when choosing a therapeutic strategy for CRLM. This might confuse both patients and referring physicians and indicate that an international high-level consensus statements and widely accepted guidelines are needed.

Introduction. Percutaneous transhepatic biliary drai­nage (PTBD) comes as safe and effective alternative when endoscopic biliary decompression is unavaila­ble. However, PTBD as invasive procedure has its own risks and complications. Our aim was to evaluate the clinical outcomes and possible benefits of an ul­trasound guided percutaneous transhepatic biliary drainage as the first step in the palliative treatment of malignant biliary obstruction. Methods. Retrospective review of patients undergoing percutaneous transhepatic biliary drainage from Ja­nuary 2014 to December 2015 at the Department of Surgery, Hospital of the Lithuanian University of He­alth Sciences was performed. Patients were reviewed for demographic data, laboratory tests, complications, outcomes, hospital stay and mortality rate. Results. During the study period ninety nine patients (median age - 68 years, (44 - 95) received 124 biliary drainage procedures for malignant obstructive jaun­dice. Prior the percutaneous drainage fifty eight pa­tients (58.6%) were unsuccessfully treated by ERCP. Forty patients (40.4%) were diagnosed with periam­pullary tumours, thirty (30.3%) had proximal/hi­lar cholangiocarcinoma, and twenty nine (29.3%) had biliary obstruction due to metastatic disease. Acute cholangitis was present in fifty two (52.5%) patients. After drainage procedure total serum bi­lirubin decreased in eighty seven (87.9%) patients (from 293.72±131.9 μmol to 193.11±117.49 μmol, p

AIM To investigate the response to hyperthermia and chemotherapy, analyzing apoptosis, cytotoxicity, and cisplatin concentration in different digestive system cancer cells. METHODS AGS (gastric cancer cell line), Caco-2 (colon cancer cell line) and T3M4 (pancreatic cancer cell line) were treated by cisplatin and different temperature setting (37 °C to 45 °C) either in isolation, or in combination. Treatment lasted for one hour. 48 h after the treatment viability was evaluated by MTT, cell apoptosis by Annexin V-PE and 7ADD flow cytometry. Intracellular cisplatin concentration was measured immediately after the treatment, using mass spectrometry. Isobologram analysis was performed to evaluate the mathematical combined effect of temperature and cisplatin. RESULTS AGS cells were the most sensitive to isolated application of hyperthermia. Hyperthermia, in addition to cisplatin treatment, did not provoke a synergistic effect at intervals from 37 °C to 41 °C in neither cancer cell line. However, a temperature of 43 °C enhanced cisplatin cytotoxicity for Caco-2 cells. Moreover, isobologram analysis revealed mathematical antagonistic effects of cisplatin and temperature combined treatment in AGS cells; variations between synergistic, additive, and antagonistic effects in Caco-2 cells; and additive and antagonistic effects in T3M4 cells. Combined treatment enhanced initiation of cell apoptosis in AGS, Caco-2, and T3M4 cells by 61%, 20%, and 19% respectively. The increase of intracellular cisplatin concentration was observed at 43 °C by 30%, 20%, and 18% in AGS, Caco-2, and T3M4 cells, respectively. CONCLUSION In addition to cisplatin, hyperthermia up to 43 °C does not affect the viability of cancer cells in a synergistic manner.

AIM To explore the outcomes and the appropriate treatment for patients with moderately severe acute pancreatitis (AP). METHODS Statistical analysis was performed on data from the prospectively collected database of 103 AP patients admitted to the Department of Surgery, Hospital of Lithuanian University of Health Sciences in 2008-2013. All patients were confirmed to have the diagnosis of AP during the first 24 h following admission. The severity of pancreatitis was assessed by MODS and APACHE II scale. Clinical course was re-evaluated after 24, 48 and 72 h. All patients were categorized into 3 groups based on Atlanta 2012 classification: Mild, moderately severe, and severe. Outcomes and management in moderately severe group were also compared to mild and severe cases according to Atlanta 1992 and 2012 classification. RESULTS Fifty-three-point four percent of patients had edematous while 46.6 % were diagnosed with necrotic AP. The most common cause of AP was alcohol (42.7%) followed by alimentary (26.2%), biliary (26.2%) and idiopathic (4.9%). Under Atlanta 1992 classification 56 (54.4%) cases were classified as “mild” and 47 (45.6%) as “severe”. Using the revised classification (Atlanta 2012), the patient stratification was different: 49 (47.6%) mild, 27 (26.2%) moderately severe and 27 (26.2%) severe AP cases. The two severe groups (Atlanta 1992 and Revised Atlanta 2012) did not show statistically significant differences in clinical parameters, including ICU stay, need for interventional treatment, infected pancreatic necrosis or mortality rates. The moderately severe group of 27 patients (according to Atlanta 2012) had significantly better outcomes when compared to those 47 patients classified as severe form of AP (according to Atlanta 1992) with lower incidence of necrosis and sepsis, lower APACHE II (P = 0.002) and MODS (P = 0.001) scores, shorter ICU stay, decreased need for interventional and surgical treatment. CONCLUSION Study shows that Atlanta 2012 criteria are more accurate, reduce unnecessary treatments for patients with mild and moderate severe pancreatitis, potentially resulting in health costs savings.

Introduction: Tumor grade, one of the most important risk factors for survival, is routinely determined after examining the biopsy material or a surgically removed specimen. The aim of the study was to analyze computed tomography (CT) perfusion parameters and diffusion-weighted imaging apparent diffusion coefficient (ADC) values in pancreatic ductal adenocarcinoma (PDAC) and to establish the diagnostic value of these modalities determining the tumor grade. Materials and Methods: A prospective clinical study included 56 subjects with PDAC. All the patients had a local perfusion assessment and ADC measurement of the tumor. For the prediction of poor tumor differentiation sensitivity, specificity, positive, and negative predictive values for each perfusion CT and ADC parameters based on cutoff values from ROC analysis were calculated. Results: Mean transit time (MTT) and ADC values were found to be independent prognosticators for the presence of G3 PDAC. MTT and ADC at the cutoff of 17.37 s and 1.15 × 10−3 mm2/s, respectively, appeared to be significant parameters discriminating against the differentiation grade of PDAC. If both values exceeded the defined cutoff point, the estimated probability for the presence of G3 PDAC was 89.29%. Conclusion: The MTT parameter, calculated with the deconvolution method, and the ADC value may serve as effective independent prognosticators identifying poorly differentiated PDAC.

Background and Objectives: Both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) may lead to cachexia, sarcopenia, and osteoporosis due to different mechanisms. Neither patient gender, age, nor body weight are good predictors of these metabolic changes having a significant negative impact on the quality of life (QOL) and treatment outcomes. The aim of this study was to evaluate radiological changes in body composition and to compare them with manifestations of exocrine and endocrine pancreatic insufficiency, body mass, and QOL among patients with CP and PDAC. Materials and Methods: Prospectively collected data of 100 patients with diagnosed CP or PDAC were used for analysis. All patients underwent dual-energy X-ray absorptiometry (DXA), computed tomography (CT), and magnetic resonance imaging (MRI). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) was used to assess QOL. Diabetes and changes in fecal elastase-1 were also assessed. Results: There was no significant difference in skeletal muscle mass (SMM) among patients with CP and PDAC (p = 0.85). Significantly more underweight patients had low SMM (p = 0.002). Patients with CP had more pronounced pancreatic fibrosis (PF) (p &lt, 0.001). Data showed a significant relationship between a high degree of PF and occurrence of diabetes (p = 0.006) and low fecal elastase-1 levels (p = 0.013). A statistically significant lower QOL was determined in patients with PF &ge, 50% and in the CP group. Conclusions: Sarcopenia and osteoporosis/osteopenia are highly prevalent among patients with chronic pancreatitis and pancreatic cancer, and CT- and MRI-based assessment of body composition and pancreatic fibrosis could be a potentially useful tool for routine detection of these significant metabolic changes.

OBJECTIVES: The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI) for the noninvasive assessment of pancreatic fibrosis (PF).METHODS: Fifty-two patients who underwent surgical resection of the pancreas, histological examination of resection margins, preoperative abdominal MRI, and fecal elastase-1 test were enrolled in the study. Pancreatic tissue was identified on the MRI T1-, T2-, and diffusion-weighted imaging sequences. Apparent diffusion coefficient (ADC) was measured at the expected resection margin of the pancreas.RESULTS: There was a significant negative correlation between the ADC mean and histologically determined PF (r = -0.752, P = 0.001). For equal to or greater than 25% of PF, the ADC cutoff value was 1.331 or less, with a sensitivity of 77% and specificity of 88%. The unenhanced T1-weighted signal intensity ratio (T1SI) cutoff value was 172.1 or less. For equal to or greater than 50% of PF, the ADC cutoff value was 1.316 or less with a sensitivity of 85% and specificity of 88%. The highest sensitivity was obtained by combining ADC and T1SI values.CONCLUSIONS: Combining both the ADC and T1SI measurement allows the detection of early PF with good sensitivity and specificity. Magnetic resonance imaging has the advantage of being noninvasive and widely used in the clinical setting, thus making our results easily transferable to routine clinical practice.

Activated pancreatic stellate cells (PSC) play a major role in the development of chronic pancreatitis. Flavonoids (C-3-O-G) theoretically may have potential to suppress activated PSC. The aim of our study was to determine the ability of C-3-O-G to invert synthetic and metabolic activity of alcohol stimulated human pancreatic stellate cells (hPSC). In the present study we demonstrate that treatment with C-3-O-G decreased proliferation rate of ethanol activated hPSC by 51%. Synthesis of extracellular matrix proteins in activated hPSC was markedly inhibited, as shown by reduced levels of collagen I and fibronectin expression. The decrease of secretion of fibronectin by 33% and in collagen I-25% in ethanol activated and C-3-O-G treated hPSC was observed. Moreover, treatment of ethanol activated hPSC with C-3-O-G resulted in the decrease of oxygen consumption rate by 44% and reduced levels of ATP synthesis (i.e. energy production) by 41%. Hence, the effects of C-3-O-G on ethanol activated hPSC may provide new insights for the use of anthocyanins as anti-fibrogenic agents in treatment and/or prevention of pancreatic fibrosis.

Portopulmonary hypertension is one of the complications for people with end stage chronic liver disease. This condition occurs to 5-8% of people, who need liver transplantation, and it causes a higher risk of perioperative complications or these patients are even banned from this procedure. Therefore, it is very important to diagnose this pathology in time using right heart catheterization and provocative volume and dobutamine samples for evaluation of the right ventricle function. Fortunately, adequate medical treatment with its most important part – vasodilator drugs - cures portopulmonary hypertension or lowers the perioperative risk caused by this condition. This case report presents a 50-year-old male hospitalized for liver transplantation. The patient has cirrhosis of the liver caused by hepatitis C, liver failure and portopulmonary hypertension. He has been taking vasodilator drugs for almost 8 months in order to prepare for a surgical treatment and when the operation’s day came, all tests needed including echocardiography shown that the transplantation could be performed. During the operation patient’s heart function was monitored with transesophageal echocardiography. Even though the mean pulmonary arterial pressure was marginal, the operation was successful and the patient could be extubated right after the procedure. Systolic pulmonary arterial pressure of the recipient dropped from 70 mmHg to 60.

Background Hyperthermic intraperitoneal chemotherapy (HIPEC) is proposed as a promising treatment method, but fundamental information about the contribution of hyperthermia to intraperitoneal chemotherapy is lacking. The purpose of this study was to investigate the cytotoxic effect of hyperthermia and cisplatin on OVCAR-3 cells in vitro. Materials and methods Imitating the typical clinical conditions of HIPEC, OVCAR-3 cells were exposed to hyperthermia and cisplatin for 1 h. MTT viability test, flow cytometric analysis, and real-time cell and isobologram analysis were performed. Results Hyperthermia up to 42°C did not significantly increase the effect of cisplatin regarding the viability and apoptosis of OVCAR-3 cells. Moreover, an antagonistic effect of hyperthermia and cisplatin was revealed. Conclusion Our investigation of OVCAR-3 cells critically disputes the benefit of hyperthermia in ovarian cancer treatment. Further in vitro and in vivo research is essential for better understanding of the mechanisms of action of hyperthermia and its role in the treatment of epithelial ovarian cancer.

Background Laparoscopic cholecystectomy is a treatment of choice for acute cholecystitis. As an alternative treatment option in critically ill patients percutaneous cholecystostomy (PC) is performed. The aim of this study was to evaluate the clinical outcomes and possible benefit of a ultrasound guided PC in high risk patients. Methods Retrospective review of patients undergoing PC from 2008 to 2016 in Hospital of Lithuanian University of Health Sciences. Patients were reviewed for demographic features, laboratory tests, complications, hospital stay, American Society of Anaesthesiologists (ASA) physical status class and mortality rate. Results Thirty- eight patients (65.8% males) were included in the study with a median age of 77.1± 9.4. Twenty-one 0patient (71.1%) were ASA III and 8 patients (21.8%) – ASA IV. Statistically significant decrease in WBC count (from 13.9±5.25 to 8.35±5.18) and C-reactive protein level (from 212.34±120.87 to 50.96±50.45) after PC was observed. Four patients (10.5%) developed post-procedure complications including obstructive jaundice (n = 2), septic shock (n = 1) and a gallbladder empyema with liver abscess (n = 1). The mean hospital stay was 12.78 ± 9.47 days and 30-day mortality - 10.5%. Eight patients (21.1%) underwent interval surgery. Conclusion PC is a reasonable low risk management option for high-risk patients with acute cholecystitis. It can be used as a temporizing measure or as a definitive treatment option with a low number of interval cholecystectomie.

Background Endoscopic retrograde cholangiopancreatography (ERCP) is a first-choice diagnostic and treatment procedure for patients with malignant obstructive jaundice. If ERCP is impossible to perform percutaneous transhepatic biliary drainage (PTBD) acts as an alternative method. The aim was to evaluate the effectiveness and the influence of ERCP prior PTBD in the treatment of patients with malignant obstructive jaundice. Methods Retrospective review of patients undergoing PTBD from 2014 to 2015 at the Department of Surgery, Hospital of the Lithuanian University of Health Sciences was performed. Group I - ERCP prior PTBD, Group II – no ERCP prior PTBD. Length of hospital stay, total serum bilirubin values, additional interval procedures, complication and mortality rates were compared. Results Group I consisted of 66 patients and Group II of 48 patients. PTBD significantly reduced total serum bilirubin values in both groups: from 287,87±118,99µmol to 178,35±102,61µmol in Group I (p

Acute pancreatitis is a severe and frequently life-threatening disease, which can lead to pancreatic necrosis, acute lung injury, systemic inflammatory response syndrome, and other complications. In this study, we hypothesized that the expression of heme oxygenase-1 determined by the number of guanidinium thiocyanate (GT) repeats can influence the occurrence of acute pancreatitis.Patients with acute pancreatitis (n = 131) and age- and sex-matched healthy controls (n = 108) were studied. The polymerase chain reaction products were analyzed by ABI 3130 genetic analyzer and the exact size of the polymerase chain reaction products was determined by GeneMapper software. A short allele was defined as containing 27 GT repeats or fewer, whereas a long allele was more than 27 repeats.The subjects were categorized into 3 groups on the basis of the genotype results: 1 short and 1 long, 2 short, and 2 long alleles (L/L). Patients with necrotizing disease more frequently were carriers of LL genotype compared with those who had edematous acute pancreatitis. Furthermore, logistic regression analysis revealed that the presence of L/L allele type doubles the risk for developing pancreatic necrosis in patients with acute pancreatitis.The polymorphism of the GT repeats in the heme oxygenase-1 promoter region may be a risk factor for developing severe and necrotizing acute pancreatitis.

Hyperinsulinism is the most common cause of hypoglycemia in infants. In many cases conservative treatment is not effective and surgical intervention is required. Differentiation between diffuse and focal forms and localization of focal lesions are the most important issues in preoperative management. We present a case of persistent infancy hyperinsulinism. Clinical presentation, conservative treatment modalities, diagnostic possibilities of focal and diffuse forms, and surgical treatment, which led to total recovery, are discussed.

Background Emergent pancreaticoduodenectomy (EPD) is an uncommon surgical procedure performed to treat patients with acute pancreaticoduodenal trauma, bleeding, or perforation. This study presents the experience of two university hospitals with EPD. Methods Clinical data on EPD in trauma and nontrauma patients from 2002–2012 were extracted from the hepatopancreatobiliary surgery databases at Thomas Jefferson University and Kaunas Medical University Hospitals. Data on indications, perioperative variables, morbidity, and mortality rates were evaluated. Results Ten single-stage EPD patients were identified. Five underwent a classic Whipple resection, whereas five had pylorus preservation. Seven patients had traumatic indications for pancreaticoduodenectomy: three from gunshot wounds to the abdomen and four from blunt high-energy injuries (two sustained injuries by falling from height and two by direct assaults on the abdomen). Three cases of nontrauma patients had EPD surgery for massive gastrointestinal hemorrhage. The median age of the EPD cohort was 46 y (range, 19–67 y). All 10 patients were recovered and were discharged from the hospital with a median postoperative length of stay of 24 d (range, 8–69 d). There were no perioperative mortalities. Conclusions Despite a high morbidity rate and prolonged recovery, this dual institutional review suggests that EPD can serve as a lifesaving procedure in both the trauma and the urgent nontrauma settings.

ObjectivesThe use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients.MethodsThe study population consisted of 210 patients treated for SAP. In Group 1 (n= 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n= 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate.ResultsUltrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P= 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P= 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P= 0.206] were performed more frequently and earlier [at 16.6 ± 7.8days vs. 17.2 ± 6.7days (P= 0.723); at 19.5 ± 9.4days vs. 24.5 ± 14.2days (P= 0.498), and at 22.6 ± 13.5days vs. 26.7 ± 18.1days (P= 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit.ConclusionsThe results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.

Several tools have been developed for severity stratification in acute pancreatitis (AP). They include single biochemical markers and complex scoring systems, all of which aim at an early detection of severe AP to optimize monitoring and treatment of these patients. The aim of this study was to reassess and compare the value of some known and newly-introduced prognostic markers in the clinical context.We have conducted a prospective observational study. One hundred and eight patients with a diagnosis of AP and onset of the disease within last 72 h were included in this study. Clinical data and expression results of some serum biochemical markers were used for statistical analysis. The diagnostic performance of scores predicting severity and progression of AP, cut-off values, specificity, and sensitivity were established using receiver operating characteristic curve analysis.Among single biochemical markers, C-reactive protein remains the most useful. Despite its delayed increase, it is accurate, cheap, and widely available. Interleukin-6 and macrophage migration inhibitory factor seem to be new promising parameters for use in clinical routine. Pancreas specific scores (Imrie-Glasgow, pancreatitis outcome prediction) and scores assessing organ dysfunction (acute physiology and chronic health evaluation II, multiple organ dysfunction score, and Marshall score) remain of value in determining the severity, complications, and possible outcome of AP.Indication, timing, and consequences of the methods applied need to be carefully considered and incorporated into clinical assessments. Currently, there is no single prognostic marker that would cover the whole range of problems associated with the treatment of AP. The prediction of severity and progression of AP can be achieved using a series of accurate methods. The decision to undertake interventional or surgical treatment is the most complex task requiring both clinical judgment and meticulous monitoring of the patient.

The majority of surgeons agree that ampullary adenocarcinoma should be removed by partial pancreatoduodenectomy. Favoring extended resection, based on the uncertainty of the preoperative diagnosis and the higher probability of clear resection margins, we aimed to disclose the results of this surgical procedure in terms of postoperative morbidity and mortality, and to identify prognosticators of long-term survival. We documented, prospectively, 25 consecutive patients with adenocarcinoma of the papilla of Vater in whom pylorus-preserving pancreatoduodenectomy was performed. Clinical data, pathology reports, International Union Against Cancer (UICC) tumor stage, postoperative morbidity, mortality, and long-term follow-up results were evaluated. The Kaplan-Meier method and log-rank test were applied for univariate analysis. The Cox proportional hazard model was used for multivariate analysis. Postoperative mortality was 4%, overall morbidity was 32%, and pancreas-associated morbidity was 8%. Mean survival time was 53.8 months. Tumor size, N status, UICC stage, lymphatic invasion, blood vessel infiltration, R0 resection, and age of patient at the cutoff of 70 years were independent predictors of survival on univariate analysis. Multivariate analysis, however, disclosed no independent predictors of prognosis. Pancreatoduodenectomy for ampullary carcinoma is reasonable in terms of postoperative morbidity and mortality. Tumor-related factors, R0 resection, and advanced age appeared as the main predictors of survival.

Infectious complications account for approximately 80% of deaths in severe acute necrotizing pancreatitis. The objective of our study was to determine the role of invasive procedures for the develo