DIABETES MELLITUS IN PATIENTS WITH COMPENSATED LIVER CIRRHOSIS

M. COSKUN (1), S. OZDEMIR (2), C. SARKIS (1), M. KUCUR (3),

C. A. ZEYBEK (4) , S. BERK (2), E. U. ZENGIN (3), A. AYDIN (4)

(1)Balikesir University, Faculty of Medicine, Department of Internal Medicine, Division of

Gastroenterology, Balikesir, TURKEY.

(2)Istanbul University, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Gastroenterology, Istanbul, TURKEY.

(3)Istanbul University, Cerrahpasa Faculty of Medicine, Department of Biochemistry, Istanbul, TURKEY.

(4)Istanbul University, Cerrahpasa Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Istanbul, TURKEY.

Background /Aims: The liver has an important role in the glucose metabolism as in most metabolic processes. It has been reported that about 80% of patients with liver cirrhosis are glucose intolerant, with hyperglycemia after an oral glucose load, and around 25% are frankly diabetic. In this study, the prevalence of diabetes mellitus was investigated in patients with compensated liver cirrhosis.

Methodology: A total 35 compensated cirrhotic patients were included in the study (24 male, 11 female) (mean age: 52.8±7.3 yr, range: 44-61 yr). All patients were histopathologically diagnosed with cirrhosis. 16 and 19 patients were associated with hepatitis B virus and hepatitis C virus, respectively. The control group consisted of 17 healthy persons. Fasting plasma glucose and a 75 g oral glucose tolerance test (oGTT) were investigated in both patient and control groups.

Results: Fasting plasma glucose levels in both patient and control groups were normal limits. Impaired glucose tolerance was found in 22 patients (62.85%). The oGTT was found normally in all controls except for two persons (p<0.05).

Conclusions: Our findings suggested diabetes prevalence does not increase in the patients with compensated cirrhosis. However, glucose intolerant in patients with compensated cirrhosis was significantly higher than in the control group.

EVALUATION OF THE SEVERITY OF HEPATIC ENCEPHALOPATHY IN LIVER CIRRHOSIS IN THE LATE PERIOD AFTER PORTOSYSTEMIC SHUNT

A.V. DEVYATOV, A.H. BABAJANOV, L.L. MARDONOV

Republican Specialized Center of Surgery after acad. Vakhidov, Tashkent, UZBEKISTAN

Introduction: Early diagnosis of hepatic encephalopathy (HE) is one of the most important tasks in patients with liver cirrhosis (LC), planning to portosystemic shunting (PSSh). Thus, if clinical manifestations of HE are detected only in 10-25% of patients with LC, the latent form according to clinical and instrumental examination may be determined in 50-70%, which obviously requires an adequate approach to the treatment at the stage of preoperative preparation. At the same time, the analysis of long-term results of PSSh referring to the frequency and severity of HE is of particular interest.
Materials and methods: Long-term results after PSSh with dynamic clinical and instrumental verification of the severity of LE were traced in 188 patients. The criteria for assessing the severity of HE on PSSh stage were the results of the determination of critical flicker frequency (CFF) obtained by apparatus HEPAtonormTM - Analyzer («MERZ» company, Germany).

Results: In various terms after PSSh 67 (35.6%) patients died from crescent liver failure, 35 (33.0%) of them died after selective distal splenorenal anastomosis (DSRA) and 32 (39.0%) -after central PSSh. Lethality at a background of recurrent bleeding was 8.5% (16 patients, 10 (9.4%) after DSRA and 6 (7.3%) - after the central PSSh). CFF index depending on the time of observation is displayed in Table 4.12. In a 6-month period of observation the average mean of CFF made 40,6 ± 1,0 Hz after DSRA, and 40,2 ± 1,1 Hz after central PSSh (P <0.001). Within a year of observation the index has improved a little and reached 41,2 ± 1,2 Hz and 40,9 ± 1,2 Hz accordingly (P <0.001). Later was noted the reduction of the value of CFF, and if the previous index significantly decrease in all periods (P <0,05-0,001) in both groups, the average values ​​between CFF in terms of more than 1 year didn’t vary particularly and were not significant. .
Conclusion: In the remote period after PSSh depending on the type of decompression, both in reference to bleeding complications and to the frequency of liver failure and encephalopathy the crucial period was only 1 year of observation. In the future the leading cause of fatal outcomes was the increasing hepatic failure with actually the same rate after selective and central PSSh choices.

THE SEVERITY OF HEPATIC ENCEPHALOPATHY IN PATIENTS WITH CIRRHOSIS BEFORE AND AFTER PORTOSYSTEMIC SHUNTING

A.V. DEVYATOV, A.H. BABAJANOV, L.L. MARDONOV

Republican Specialized Center of Surgery after academ. V.Vakhidov, Tashkent, UZBEKISTAN

Introduction: Hepatic encephalopathy (HE) is a severe and sometimes hardly corrected complication of liver cirrhosis (LC). At present this complication attracts much attention not only from the perspective of effectiveness of conservative treatment. Social issues become relevant,

because the development and progression of even of unexpressed clinical forms of HE significantly degrade the quality of life of patients with LC.

Materials and methods: Were studied the results of the frequency of this complication before and after portosystemic shunting (PSSh). Were analyzed the results of examination and treatment of 264 patients with LE. The criteria for assessing the severity of HE on the stage of PSSh were the results of the determination of critical flicker frequency (CFF) obtained by means of

apparatus HEPAtonormTM - Analyzer («MERZ» company, Germany). All patients underwent planned operations: distal splenorenal shunt - 152 (57.6%), central PSSh - 112 (42.4%) patients.
Results: At the preoperative stage HE was diagnosed in 80.7% of patients with LC, in 56.1% of them in a latent stage. At 100.0% of cases PSSh worsens CFF (from 39,5 ± 0,9 to 37,8 ± 1,2 Hz, P <0.001). Moreover, if HE was absent prior to operation or it was in a latent form (in 75.4 % of patients), in the early postoperatine period this figure declined to 46.6%, and most patients had clinically significant symptoms of HE. Against the background of post-operative conservative treatment the tendency for improvement of the level of CFF was more pronounced after selective DSRA (39,5 ± 1,1 Hz), whereas in patients with central type of decompression the rate of CFF improved with less intensity, reaching 38 3 ± 1,2 Hz (P <0.001) to the moment of the discharge.

Conclusion. HE is one of the most frequent complications of LC and its progression demonstrates the growing insufficiency of hepatocytes. When planning PSSh, more importance should be given to assessing the severity of LE. Particular attention should be given for identifying the latent form of LE. One of the objective criteria for assessing the presence and severity of the LE is to determine CFF by means of «HEPAtonormTM - Analyzer». The device allows to identify the latent form of HE, as well as according to the received initial value of CFF (less or more than 38 Hz) to determine the risk of expected interventions

ADVANCES IN SURGICAL CARE OF PANCREAS CANCER

B.EDIL

Johns Hopkins, Department of Surgery and Oncology, Baltimore, USA

Pancreatic cancer was first described in 1761 by Giovanni Battista Morgagni even though the majority of physicians did not believe it existed until 1886 when Nicholas Senn described the clinical phenomenon of painless jaundice. William Halsted of The Johns Hopkins Hospital in 1899 reported the first successful resection an ampullary cancer with a transduodenal approach and reanastomosis of the pancreatic and bile ducts to the duodenum. However, the patient died 6 months later from recurrent disease invading the head of the pancreas. Whipple established the pancreaticoduodenectomy the procedure of choice rather than the two stage operation. The next forty years the Whipple was performed in limited numbers and mortality in the 1970s was 25%. Until a series from Johns Hopkins published in the Annals of Surgery showed 187 consecutive resections with a mortality of 2%. Currently Johns Hopkins has done 5800 whipples with a 2.8 % mortality. Recent advances in surgical technique include the implementation of laparoscopic techniques. At Johns Hopkins since 2007 we have performed 115 laparoscopic distal pancreatectomies and 35 laparoscopic whipples. This requires a different technical approach, however, maintains the same oncologic principals. We have shown improved outcomes (p<.05) in blood loss, morbidity with equivalent lymph node harvest and margin status to the open operation. Even with improving surgical techniques and our patients recovering from the operation quicker with less morbidity the five year survival has not changed when you compare the 1990s to 2000 and 2010. Therefore new innovative therapies are required. Immunotherapy is one of the new therapies we are currently pursuing. We have used for the last ten years an allogeneic GM-CSF secreting pancreas cancer vaccine. Our most recent clinical trial is a randomized neoadjuvant GM-CSF pancreas cancer vaccine which is administered prior to surgery with or without low dose cyclophosphamide. This trial revealed the ability to sequester lymphocyte aggregates into the pancreatic cancer, in a safe and effective manner. In conclusion there are many advancements that are needed in the treatment of pancreatic cancer. In the last several years we have modified our surgical approach to involve more minimally invasive techniques. In addition we have added new therapeutic option of immunotherapy with an immune modulator to help investigate and treat pancreatic cancer.

Date: 2014-12-28; view: 815