Dr. Pulkit Nandwani

Exocrine Pancreatic Insufficiency (EPI), also called pancreatic deficiency, is a disorder where the pancreas is unable to produce the sufficient amount of enzymes that are required to digest food. The pancreatic enzymes help to break down and absorb nutrients from the food in the small intestine. So, this disease causes nutritional deficiencies.

Causes of Exocrine Pancreatic Insufficiency
This condition is generally caused as a complication of other diseases because EPI develops only as a result of severe damage to the pancreas. The following reasons can cause EPI:

1. Inflammation of the pancreas: After surgery in the pancreas, stomach or the intestines, there may be inflammation in the pancreas as a post-surgical complication. A high content of triglyceride fat in the blood can also cause pancreatic inflammation and hinder the secretion of the enzymes.
2. Chronic Pancreatitis: In this disease, the pancreatic ducts are swollen and blocked and so the digestive enzymes cannot be passed into the small intestine. This condition is often caused by a heavy consumption of alcohol.
3. Cystic Fibrosis: The digestive fluids and enzymes become thick and sticky and block the passageways of the pancreas and other organs like the lungs and the kidneys. This can obstruct secretion and passage of enzymes afterwards.
4. Shwachman-Bodian-Diamond syndrome: This is an autosomal recessive genetic condition where enzyme-producing pancreatic cells are not formed properly. This rare disorder causes a number of associated disorders like bone marrow diseases, skeletal defects and exocrine pancreatic insufficiency.

Symptoms of Exocrine Pancreatic Insufficiency
The symptoms appear in the middle stages of the disease when the process of absorption of nutrients has already been affected. The common warning signs are:

1. Digestive problems like gas, diarrhea and indigestion because the food remains mostly undigested.
2. Severe and frequent stomach pain in the lower abdominal region
3. Greasy stools due to the excretion of undigested fat
4. Rapid loss of weight and body mass due to mal-absorption of nutrients
5. Constantly feeling bloated and full even if you have not eaten anything
6. A general sense of fatigue and exhaustion
7. Excessive bleeding from small wounds because protein deficiencies hamper blood clotting
8. Pain in the muscles and bones
9. Increased susceptibility to infections of the body systems
10. Anemia
11. Joint pains
12. Abnormal swelling of the limbs or edema

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Any surgical procedure requires the creation of a wound and then a subsequent closure by the repositioning and securing the surgical flaps by suturing to allow optimum healing. A suture is a strand or thread used for the approximation of tissues and also for ligation off blood vessels. Suturing is the act of sewing or bringing tissues or the flap edges together and holding them in apposition until normal tissue healing takes place. Placement of sutures helps the wound to withstand normal functional stresses and to resist opening of the wounds.

Suturing techniques:

1. Interrupted Suture-Sling Suture - The suture is passed through both the edges at an equal depth and distance from the incision, needle penetration should be 3mm from wound edges and the knot is tied. It is the most commonly used suture. Advantages of this technique are as follow
   • It is strong and can be used in areas of stress.
   • Successive sutures can be placed according to individual requirement
   • Each suture is placed independently and the loosening of one suture will not produce any loosening of the other.
   • A degree of eversion can be controlled.
   • If the wound becomes contaminated, infected or if there is a formation of hematoma, removal of a few sutures is possible that and provides a satisfactory treatment.
2. Continuous over and over suture - A simple interrupted suture is placed first and the needle is then reinserted in a continuous manner in such a way that the suture passes perpendicular to the incision line below and obliquely below. The suture is ended by passing a knot over the untightened end of the suture. It provides a rapid technique for closure and distributes the tension equally over the suture line.
3. Continuous locking suture - In this technique, locking is provided by withdrawing the suture through its own loop. The suture passes perpendicular to the incision line. The locking prevents excessive tightening of the suture as the wound closure progresses.
4. Mattress suture - These sutures can be horizontal or vertical. These are used for resisting a muscle pull, evert the wound edges and to adapt the tissue flaps tightly to the underlying structures.
   • The horizontal mattress suture gives a broad contact of the wound margins. In this suture, the needle is passed from one edge of the incision to another and then again from the latter edge to the first edge in a horizontal manner, after which a knot is tied. The distance of the needle penetration from incision line and the depth of needle penetration is the same for each entry point, but the horizontal distance of the points of penetration on the same side of the flap differs.
   • The vertical mattress suture is similar to the horizontal mattress, except that, all the factors remaining constant, the penetration depth varies. It is used for the closure of deep wounds.
5. Figure of eight suture - The figure of eight suture can be used for the closure of small gaping wounds like an extraction suture closure after removal of a tooth.
6. Subcuticular suture - The subcuticular layer of the tough connective tissue if sutured will aid in holding together skin edges in a close approximation when better cosmetic results are desired. Continuous short lateral stitches are taken beneath the epithelial layer of the skin. The ends of the suture come out at each end of the incision and are knotted together. This type of suturing leaves back a cosmetic scar.

Some common types of surgical knot tying used during a surgical procedure are

1. Square knot - It is also known as the standard knot or the Reef knot method. It is a special knotting technique in which the knots are securely tied. Four throws of the suture material are placed in position and the ends are cut long.

2. Surgeon’s knot - It is formed by two throws of the suture around the needle holder on the first tie and one throw in the opposite direction in the second tie.

3. Granny’s knot - It is also called as the slip knot technique. It is used when using silk, chromic catgut or the plain catgut suture material. It involves a tie in one direction followed by a second tie in the same direction and a third tie in the opposite direction to square the knot and hold it securely.

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Even though brain aneurysms are becoming common these days, not all of them are required to be treated. In some cases, the physician may choose to observe an aneurysm closely before adopting any treatment measure. But in patients in whom an aneurysm has progressed to a severe level, there are two treatment options:

1. Open surgical clipping
2. Endovascular therapy or coiling

Open surgical clipping for brain aneurysms:
This procedure is typically performed by a neurosurgeon who makes an incision in the head. An opening in the bone is made, and then a clip is positioned by dissecting through the spaces of the brain. This aids in preventing the flow of blood into an aneurysm. In this procedure, the patient is required to stay in the hospital for two to three nights after which he or she is discharged.

Considerable modifications have been made in the open surgery techniques in the recent years. Neurosurgeons are now able to perform eye brow incisions or mini craniotomies for clipping an aneurysm. In these procedures, a small incision is cut out in the skin above the eyebrow for making a window. A tiny clip is placed across the mouth of an aneurysm to help it heal. But it is worthy of mention here that these are all invasive procedures and take relatively longer time to recover compared to the coiling process.

Endovascular coiling:

• This treatment is also performed by a neurosurgeon, and it has been proved that this process is exceptionally suitable for patients with a ruptured aneurysm. Endovascular coiling is often done in coalesce with an angiogram, where a catheter is inserted into the vessel over the hip, which is then gradually carried to the vessels of the brain and finally to an aneurysm.
• Then the coils are packed to the point where it rises from the blood vessel, which prevents the blood from flowing intothe blood vessel. Most patients undergoing this minimally invasive procedure can go home the day following the surgery. The success rate of this process is very high, and over 125,000 patients have been treated all across the globe with the help of detachable platinum coils.
• Over the last few years, a substantial amount of advancements have taken place in the endovascular techniques. Recent developments show the use of flow diverting embolization devices, which are similar to a stent and are placed in the primary vessel, adjacent to an aneurysm. It diverts the flow away from an aneurysm and therefore, allows the neurosurgeons to treat the brain aneurysms, which were previously considered inaccessible and untreatable.

Both the procedures are quite efficient in treating a brain aneurysm. The most suitable option is dependent on a host of factors such as size, shape, location and overall health condition of the patient.

In case you have a concern or query you can always consult an expert & get answers to your questions!