[Antibiotic use in necrotizing pancreatitis. Results of a controlled study]

BACKGROUND AND OBJECTIVE

The clinical course and death rate in acute necrotizing pancreatitis (ANP) are largely determined by septic complications as part of bacterial invasion of the necrotic tissues. It remains unclear whether antibiotic prophylaxis reduces bacterial invasion of the necroses or septic complications. It was, therefore, the aim of this study to evaluate the effect of prophylactic administration of antibiotics to patients with ANP.

PATIENTS AND METHODS

In a prospective randomized study 13 patients with ANP and sterile necroses (quantified by contrast-enhanced computed tomography) were given twice daily 200 mg ofloxacin and twice daily 500 mg metronidazole intravenously. The results were compared to those in a control group of patients with ANP (n = 13) who had not initially received antibiotics. In both patient groups fine-needle biopsies of the necrotic areas were performed on days 1, 3, 5, 7 and 10. If there was evidence of infection, antibiotics were then also given to patients of the control group.

RESULTS

The extent of the necroses was the same, 40%, in both groups. These necroses became infected in a median of 9.5 (treated group) and 10 days (untreated group). The clinical course, documented by the APACHE II score, showed significant improvement under antibiotic treatment (days 1-5-10: scores 15-13.0-9.5). In the (initially untreated) control group the clinical condition deteriorated significantly (days 1-5-10: score 11.5-15.0-16.0). The changes from days 1 to 5, 5 to 10 and 1 to 10 were highly significant (Wilcoxon test, P < 0.01). None of the patients in the antibiotic group died within the first 3 weeks, but 2 of the 13 in the control group died.

CONCLUSION

Antibiotic prophylaxis neither prevented nor delayed bacterial infection of the necrotic pancreas. But it significantly improved the clinical course if started before the onset of infection of the pancreatic necroses.

The induction of apoptosis in proliferating human fibroblasts by oxygen radicals is associated with a p53- and p21WAF1CIP1 induction

The role of reactive oxygen species (ROS) generated by hypoxanthine/xanthine oxidase (HX/XO) in the induction of apoptosis was studied in the human fibroblast cell line WI38. Apoptosis but not necrosis was observed in proliferating fibroblasts after 48 h incubation with 1 mM HX and 0.05 U/ml XO. Induction of apoptosis was hindered by catalase. Cell-cycle analysis revealed a reduction of cells in the S/G2 phase 24 and 48 h after stimulation, suggesting that ROS induce a G1 arrest in proliferating fibroblasts. This was supported by an accumulation of p53 and the cdk inhibitor p21WAF1/CIP1. Since apoptosis was not inducible in senescent fibroblasts our data indicate that ROS mainly induces apoptosis in proliferating cells.

Overexpression of intercellular adhesion molecule-1 (ICAM-1) in pancreatic adenocarcinoma in comparison with normal pancreas

To elucidate the role of intercellular adhesion molecules (ICAMs), which has not been well understood in pancreas, we investigated the localization and expression of ICAM-1 by immunohistochemistry and in situ hybridization (ISH) in pancreatic adenocarcinoma and in normal pancreas. The localizations of ICAM-2 and ICAM-3 were also investigated by immunohistochemistry. In normal pancreas, acinar cells, duct epithelial cells, and Langerhans islet cells failed to stain with anti-ICAM-1, anti-ICAM-2, and anti-ICAM-3 antibodies. These cells showed no expression of ICAM-1 mRNA. On the other hand, various percentages of carcinoma cells were stained with anti-ICAM-1 antibody, while no carcinoma cells were stained with anti-ICAM-2 and anti-ICAM-3 antibodies. ICAM-1 mRNA expression was also observed in carcinoma cells, and ICAM-1 mRNA expression was associated with localization of the ICAM-1 protein. These results suggest that ICAM-1 expression is up-regulated in pancreatic adenocarcinoma cells and that ICAM-1 is involved in malignant processes in pancreas.

Diagnostic value of CA 19-9 in patients with pancreatic cancer and nonspecific gastrointestinal symptoms

Serum expression of the tumor marker CA 19-9 was studied in 2119 patients. The discriminating capacity between benign and malignant disease was high for CA 19-9, especially in patients with pancreatic cancer (n = 347). The sensitivity of CA 19-9 was 85%. In patients who were Lewis blood type positive, the sensitivity increased to 92%. CA 19-9 levels were significantly lower in patients with resectable tumors (n = 126) than in those with unresectable tumors (n = 221, P < 0.0001; sensitivity 74% vs. 90%). CA 19-9 levels dropped sharply after resection but normalized in only 29%, 13%, and 10% of patients with stage I, II, and III tumors, respectively. In unresectable tumors no significant decrease in CA 19-9 levels after laparotomy or bypass surgery was found. Among patients with the same tumor stage, the median survival time in those whose CA 19-9 levels returned to normal after resection was significantly longer than in those who had postoperative CA 19-9 levels that decreased but did not return to normal (stage I, 33 months vs. 11.3 months; stage II, 41 months vs. 8.6 months; and stage III, 28 months vs. 10.8 months). In patients with recurrent disease, 88% had an obvious increase in CA 19-9 levels. CA 19-9 measurement is a simple test that can be used for diagnosis, for evaluation of resectability, and for prediction of survival after surgery and recurrences.

Celiac artery adjuvant chemotherapy. Results of a prospective trial

CONCLUSION

Celiac artery infusion (CAI) seems to be a qualified and successful method for adjuvant treatment of pancreatic cancer. To improve the dismal prognosis of resected pancreatic cancer patients, we performed postoperative regional chemotherapy via the celiac axis.

BACKGROUND

From 1994-1995, 20 patients with pancreatic cancer (18 ductal adenocarcinoma, 2 cystadenocarcinoma) received adjuvant celiac axis intra-arterial infusions (CAI) after resection of their tumors. Sixteen patients had macroscopically complete tumor removal (R0/R1 resection, 80% of the patients), whereas four patients had gross residual disease remaining after resection (R2 resection, 20% of the patients). Postoperative tumor stages were UICC I in 1 patient, UICC II in 3 patients, and UICC III in 16 patients.

METHODS

CAI was performed for six postoperative cycles via catheters placed into the celiac artery using Seldinger's technique. The chemotherapeutic protocol consisted of mitoxantrone (Novantron), Wyeth-Lederle (Münster, Germany) 10 mg/m2 (d 1), folinic acid (Leucovorin, Wyeth-Lederle, or Rescuvolin, Medac, Hamburg, Germany) 170 mg/m2 for 10 min, followed by 5-FU (Fluoroblastin, Farmitalia, Freiburg, Germany) 600 mg/m2 for 120 min (d 2-4), and Cisplatin (Cisplatin-medac, Medac) 60 mg/m2 (d 5). The cycles were repeated after a rest period of 4 wk. Cisplatin infusions were accompanied by supportive antiemetic (8 mg Tropisetrone i.v. [Navoban, Sandoz, Nürnberg, Germany] and 8 mg Dexametason i.v.) and diuretic measures.

RESULTS

Toxicity WHO III occurred in 8% of 100 cycles, and no toxic side effects WHO IV were encountered. The median survival of 21 mo in the treated group was nearly twice as long as the 9.3 mo of a historical matched control group (p < 0.0003). CAI seems to be a qualified and successful method for adjuvant treatment of pancreatic cancer.

Natural course of acute pancreatitis

Acute pancreatitis comprises, in terms of clinical, pathologic, biochemical, and bacteriologic data, four entities. Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations; pancreatic pseudocyst and pancreatic abscess are late complications after necrotizing pancreatitis, developing after 3 to 5 weeks. Determinants of the natural course of acute pancreatitis are pancreatic parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis, biologically active compounds in pancreatic ascites, and infection of necrosis. Early in the course of acute pancreatitis multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. During the late course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications. The infection of pancreatic necrosis occurs in 8% to 12% of acute pancreatitis and in 30% to 40% of patients with necrotizing pancreatitis. Bacteriologic analysis of intraoperative smears and aspirates reveals predominantly gram-negative germs deriving from the intestine, most frequently Escherichia coli. It has been confirmed that after necrotizing pancreatitis a considerable large group of patients suffer long-lasting exocrine and endocrine insufficiency.

Multimodal therapies in ductal pancreatic cancer. The future

CONCLUSIONS

Intra-arterial infusion chemotherapy via the celiac axis combined with external beam radiotherapy might be an effective method for palliative and perioperative multimodal treatment in pancreatic cancer. To improve the dismal prognosis in resectable and nonresectable pancreatic cancer, the results of multimodal palliative, adjuvant, and neoadjuvant therapies were reviewed and put into perspective with the results of two intra-arterial palliative and adjuvant treatment studies conducted at our department. The benefits and pitfalls of each method were outweighed, resulting in a concept for performing intra-arterial chemotherapy with radiotherapy in nonresectable stage UICC-III pancreatic cancer that eventually will be developed as a combined neoadjuvant/adjuvant treatment of all potentially resectable ductal pancreatic carcinomas.

[Duodenum preserving resection of the head of the pancrease in therapy of pancreas divisum]

In 1-6% of the patients who are investigated by endoscopic retrograde cholangio-pancreatography a pancreas divisum can be found. In some patients pancreas divisum can lead to an acute relapsing and finally chronic pancreatitis (CP). Surgical intervention in these cases seems to offer a good chance of recovery. We report our experience with the duodenum-preserving resection of the head of the pancreas in 12 patients with pancreas divisum and CP. In all patients the preoperative evaluation showed clinical, functional or radiological signs of CP. The duodenum-preserving resection of the head of the pancreas was carried out in all patients without perioperative mortality. Ten postoperative versus eight preoperative patients showed a pathological exocrine function of the pancreas. Endocrine function, measured by the oral glucose tolerance test (OGTT), improved postoperatively in two patients. Eleven patients who were investigated after a mean follow-up time of 31 months (3-75 months) were completely pain free. No late mortality occurred. OGTT revealed a diabetic endocrine function in two patients. Disturbed exocrine pancreatic function had to be substituted in nine patients. One patient had to be reoperated by duct incision and renewal of the pancreatico-jejunostomy 10 months after the first operation. In conclusion, the duodenum-preserving resection of the head of the pancreas reduced pain in all patients with pancreas divisum and CP and may lead to an improvement of endocrine pancreatic function. Other, nonresecting procedures or endoscopic interventional therapy should be avoided in these patients.

Surgical treatment of infected necrosis

Over the years, experience has shown that the cornerstone for improved survival in patients with infected pancreatic necrosis is an early, precise diagnosis followed by adequate drainage combined with modern intensive care management. In experienced hands, this goal can be achieved with different surgical approaches, provided that all septic collections are thoroughly removed and that reexploration is performed promptly if there is evidence of ongoing sepsis. If there is any concept preferable, and under what conditions, future large-scale randomized trials with precise and comparable patient stratification will have to demonstrate it.

[Duodenum preserving resection of the head of the pancreas: a new standard operation in chronic pancreatitis]

Between 1972 and 1993, 298 patients with chronic pancreatitis underwent a duodenum-preserving pancreatic head resection (DPPHR). The early and late outcomes were prospectively analyzed. An operative mortality rate of 1%, a postoperative morbidity rate of 28.5% and a relaparotomy rate of 5.7% for the DPPHR were competitive with the rates for Whipple resection. After a median late follow-up of 6 years (range: 1 to 22 years), late mortality was 9%; 88% of the patients had no or infrequent episodes of pain and 63% were completely rehabilitated professionally. Only 6 patients developed diabetes mellitus early postoperatively. Our study proves that the duodenum-preserving pancreatic head resection provides better results than the Whipple resection. Therefore, this operation should be adopted as a new standard operation in patients with chronic pancreatitis.

Duodenum-preserving pancreatic head resection: Long-term results

Early and late results from 298 patients with chronic pancreatitis who were surgically treated by means of duodenum-preserving pancreatic head resection (DPPHR) were prospectively analyzed. The aim of this operative procedure is to treat complications of chronic pancreatitis caused by inflammatory enlargement of the pancreatic head by decompressing the common bile duct, the pancreatic duct, the duodenum, and the retropancreatic intestinal vessels. End points of the study were early and late postoperative outcome. The follow-up period ranged from 1 to 22 years with a median follow-up of 6 years. In-hospital mortality was 1%, postoperative morbidity was 28.5%, and the rate of repeat laparotomy was 5.7%. Diabetes mellitus developed early in the postoperative period in six patients (2%). After a median follow-up of 6 years, late mortality was 8.9%. In the late follow-up period 88% of our patients were completely free of pain or had infrequent episodes and 63% were able to return to work. DPPHR might be considered as an alternative surgical technique in the treatment of chronic pancreatitis if the dominant lesion is in the pancreatic head.

Nuclear accumulation of p53 correlates significantly with clinical features and inversely with the expression of the cyclin-dependent kinase inhibitor p21(WAF1/CIP1) in pancreatic cancer

Recent studies have suggested a p53-independent expression of p21(WAF1/CIP1). We investigated the correlation between p53 overexpression and the expression of p21(WAF1/CIP1) in 57 patients with pancreatic adenocarcinoma. By means of reverse transcription and polymerase chain reaction (RT-PCR), we examined the mRNA levels of WAF1/CIP1 and compared them with the p53 status in 20 patients and in a further six pancreatic tumour cell lines. In pancreatic cancer tissues, immunohistological evaluation revealed a significant correlation between active p53 and p21(WAF1/CIP1) (P < 0.005) as well as WAF1/CIP1 mRNA expression (P < 0.005). This coherence was also evident in human pancreatic carcinoma cell lines. The analysis of p53 and p21(WAF1/CIP1) expression in relation to clinicopathological features revealed a significant correlation between p53 overexpression and tumour stage, tumour size, grading and lymph node metastases, whereas p21(WAF1/CIP1) expression correlated only with tumour size. We conclude that the expression of p21(WAF1/CIP1) normally depends on active p53, but that there may also exist p53-independent pathways of induction that reduce the correlation of p21(WAF1/CIP1) to clinicopathological features.

Similar morphological and intracellular biochemical changes in alcoholic acute pancreatitis and ischemic acute pancreatitis in rats

Pancreatic hyperstimulation with simultaneous duct obstruction does not cause the typical features of acute pancreatitis, therefore the role of an additional challenge, such as either ethanol intoxication or short-term ischemia, was studied. Alcoholic pancreatitis was induced in 28 rats by acute ethanol intoxication (0.25 LD50) and an obstruction/hyperstimulation mechanism (clip of the biliopancreatic duct for 20 min and intravenous stimulation with 5 U of cholecystokinin and secretin each). Ischemic pancreatitis was performed by obstruction/hyperstimulation and subsequent pancreatic ischemia by clamping the supplying arteries for 40 min. The macro- and microscopic alterations were evaluated and graded by a scoring system. Additionally, the pancreas was removed in 50% of the animals and the pancreatic acini were prepared. From those acini the intracellular enzymes trypsinogen, kallikreinogen, amylase, lipase, glucuronidase, and acidic phosphatases were determined. While obstruction/hyperstimulation, 40 min of ischemia, or ethanol alone did not induce acute pancreatitis, a combination of obstruction/hyperstimulation with either ethanol or ischemia resulted in acute pancreatitis in 68 and 60% of treated rats, respectively. Similarly, both models were characterized by extrapancreatic fat necrosis and acinar necrosis at the periphery of the lobules. Almost all intracellular enzymes were elevated in both pancreatitis models compared to sham-operated controls. Both alcohol and ischemia were insults that sensitize the pancreas to develop acute pancreatitis after obstruction/hyperstimulation. Since the observed morphologic and enzymatic alterations in both models are very similar, alcohol and ischemia might have some common pathways by which they make the pancreas vulnerable to enzymatic attacks.

The role of laparoscopy and ultrasonography in pancreatic head carcinoma

Objective: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.

Summary Background Data: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.

Methods: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).

Results: “Occult” metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).

Conclusions: Staging laparoscopy is indispensable in the detection of “occult” intraabdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.

[PET in pancreatic tumor of unknown origin--luxury or value?]

18FDG-positron emission tomography (PET) was performed preoperatively in 159 patients (89 pancreatic cancers, 48 inflammatory pancreatic tumors, 22 benign tumors) with pancreatic mass of unknown origin and its diagnostic value (ROC analysis) was compared with ERCP and computed tomography. In patients with normal fasted blood glucose level (< 130 mg%) and without active inflammation (n = 126), diagnostic value of PET was equal to ERCP (0.94) and higher than CT (0.84; p < 0.02); PET showed in 88% of cases no prediction of resectability or local tumor infiltration, no influence on explorative celiotomies, in 93% no increase of preoperative hospital stay, in 4% influence on surgical strategy, in 5% metastases as additional information. Though its additional information gain for the surgeon remains limited, PET is certainly a diagnostic achievement with high diagnostic value in preselected patients.

CA 19-9 serum course and prognosis of pancreatic cancer

CONCLUSION

CA 19-9 measurement is a simple test that can be used for diagnosis as well as for prediction of resection, survival rate after surgery, and recurrences.

METHODS

Serum expression of the tumor marker CA 19-9 was studied in 2119 patients.

RESULTS

The discriminating capacity between benign and malignant disease was high for CA 19-9, especially in patients with pancreatic cancer (n = 347). The sensitivity of CA 19-9 was 85%. In patients who were Lewis blood type positive, the sensitivity increased to 92%. CA 19-9 levels were significantly lower in patients with resectable tumors (n = 126) than in those with unresectable tumors (n = 221, p < 0.0001) (sensitivity 74 vs 90%). CA 19-9 dropped sharply after resection, but normalized only in 29, 13, and 10% in patients with stage I, II, and III, respectively. In unresectable tumors no significant decrease of CA 19-9 after laparotomy or bypass operation was found. In patients of the same tumor stage, the median survival time in those whose CA 19-9 levels returned to normal after resection was significantly longer than in those with postoperative CA 19-9 levels that decreased, but did not return to normal (in stage I, 33 vs 11.3 mo, in stage II, 41 vs 8.6 mo, and in stage III, 28 vs 10.8 mo). In patients with recurrent disease, 88% had an obvious rise in CA 19-9 levels.

CAM 17.1--a new diagnostic marker in pancreatic cancer

CAM 17.1-Ab is a recently described monoclonal antibody that detects a mucus glycoprotein with high specificity for intestinal mucus, particularly in the colon, small intestine, biliary tract and pancreas. We investigated the expression and release of CAM 17.1 in pancreatic carcinoma cell lines and tissue specimens of normal pancreas, chronic pancreatitis and pancreatic cancer. CAM 17.1 was weakly expressed on normal ductal cells and chronic pancreatitis, whereas it was overexpressed in pancreatic cancer. Serum analysis using a new enzyme-linked antibody sandwich assay (CAM 17.1/WGA) of patients with chronic pancreatitis, pancreatic cancer or other gastrointestinal cancer and of healthy blood donors revealed a high sensitivity (67%) and excellent specificity (90%) of CAM 17.1/WGA assay in pancreatic cancer. In comparison with the tumour marker CA19-9, the sensitivity of the CAM 17.1/WGA assay was similar to the sensitivity of CA 19-9 (67% and 76%, P = 0.22), whereas the specificity of CAM 17.1/WGA assay was higher than in CA 19-9 (90% compared with 78% in chronic pancreatitis, P > 0.05).

[Duodenum preserving pancreatic head resection in chronic pancreatitis with inflammatory tumor in the pancreas head]

15 to 30% of the patients with chronic pancreatitis develop an inflammatory mass in the pancreatic head. The leading symptoms of these patients are severe upper abdominal pain and complications of the surrounding organs. From 1969 to 1995, 380 patients were treated with a duodenumpreserving pancreatic head resection. The cause of the disease was alcohol abuse in 81%. 93% of the patients suffered from severe pain with recurrent pain attacks. CT-scan revealed enlargement of the pancreatic head (> 4 cm in diameter) in 79% of the patients. 83% of the patients had an impaired exocrine pancreatic function; 48% of the patients had an impaired glucose tolerance or were diabetic. The hospital mortality was 0.8%; 5% of all patients had to be reoperated. The mean duration of the hospitalization was 13.9 days. 89% of the patients showed an unchanged endocrine function in the early postoperative course. The glucose metabolism was improved in 9%, 2% had a deteriorated function. The duodenum-preserving pancreatic head resection is a procedure with a low postoperative mortality and morbidity without deterioration of the endocrine pancreatic function.

Influence of etiology on the course and outcome of acute pancreatitis

It has been supposed that there are differences with regard to clinical course and outcome due to the underlying etiological factor in acute pancreatitis. Therefore, the objective of this study was to analyze the severity of the disease, serum enzymes, indicators of necrosis, systemic complications, and mortality in acute pancreatitis with regard to the etiology. One hundred ninety patients with acute pancreatitis (127 male, 63 female) were studied prospectively and subdivided into three etiological groups: (i) alcohol, (ii) gallstones, and (iii) other causes and idiopathic acute pancreatitis. Severity scores (Ranson and Bank) and findings by contrast-enhanced computed tomography were similar in all three groups. Analysis of serum enzymes [lipase, aspartate aminotransferase (ASAT)] and indicators of necrosis (C-reactive protein, alpha 1-antitrypsin, alpha 2-macroglobulin, and lactate dehydrogenase) showed only for ASAT within 24 h significantly higher levels in biliary acute pancreatitis in comparison with the other groups. There were no differences in the rate of infected pancreatic necrosis and mortality in alcohol-related acute pancreatitis (31 and 5.3%), biliary acute pancreatitis (38 and 10%) and acute pancreatitis due to other etiological factors (43 and 5.5%). In conclusion, this study clearly showed that once the pathogenetic mechanisms have initiated the disease, the course and outcome of acute pancreatitis are not influenced by the underlying etiological factor.

Plasma concentrations of endotoxin and antiendotoxin antibodies in patients with multiple injuries: a prospective clinical study

OBJECTIVE

To investigate the time course of endotoxaemia and its effects on the synthesis of antiendotoxin antibodies in patients with multiple injuries.

DESIGN

Prospective clinical study.

SETTING

University hospital, Germany.

PATIENTS

40 Patients with multiple injuries and 20 healthy volunteers who served as controls.

INTERVENTIONS

Blood samples were collected up to 10 days after injury and the concentrations of endotoxin, antiendotoxin antibodies to four endotoxins, and for anti-alpha-haemolysin of Staphylococcus aureus were measured. The kinetics of endotoxaemia and antiendotoxin antibodies were investigated.

RESULTS

Endotoxaemia peaked 0-3 hours after injury at 0.425 EU/ml and decreased thereafter to 0.04 EU/ml within five days. Total concentrations of IgM, IgA, and IgG increased continuously after day 3 (p < 0.05), but the specific IgM response to all endotoxins was only temporary and the relative content of specific antibodies to all endotoxins peaked at day 3 (p < 0.05). Antiendotoxin antibodies of IgM class cross-reacted among themselves. There was no general increase in specific antiendotoxin antibodies of IgA and IgG class. The relative content of specific antibodies to alpha-haemolysin of S aureus of all classes of immunoglobulins (IgM, IgA, IgG) remained on the same level from day 0-10.

CONCLUSION

Multiple injuries are associated with early and temporary endotoxaemia which causes specific increases in antiendotoxin antibodies of the IgM-class. IgM antibodies to endotoxins cross-react among themselves.

Serous cystadenocarcinoma of the pancreas

The mucinous type of cystadenoma of the pancreas is known to have malignant potential, whereas the serous type is believed to be benign. Therefore, the therapeutic strategies for serous cystadenomas are less aggressive than in mucinous cystadenoma, where complete operative resection is the procedure of choice. A patient with a biopsy-proven serous cystadenocarcinoma with a lymph node metastasis is reported. Considering the reported case and a review of the literature, the origin of serous cystadenocarcinoma appears to be from cystadenoma lesions. Even if this development of cystadenocarcinoma in pre-existing serous cystadenoma lesions is a rare entity, a less aggressive treatment of this lesion should be avoided in favor of resection procedures because of the good chance of cure.

[Solid pseudopapillary tumors of the pancreas]

We report on three female patients with solid pseudopapillary tumors of the pancreas. The histogenetic origin of this entity is still unclear. The tumor, usually occurring in young women, forms large masses (up to 10 cm in diameter) before becoming symptomatic. Metastases have very rarely been reported. In contrast to other pancreatic tumors, the main pancreatic duct was displaced, but of normal caliber without stenosis, in all our patients. Despite the large size of the tumors, they were curatively resected in all three cases. Two of the tumors infiltrated the parenchyma or adipose tissue of the pancreas but did not spread into the lymph nodes or other organs. All of the patients are alive and without signs of tumor recurrence up to 8 years after surgical resection.

Regional chemotherapy directed by individual chemosensitivity testing in vitro: a prospective decision-aiding trial

A prospective decision-aiding trial was performed to select drugs for regional chemotherapy of various liver tumors (n = 36) by individual drug testing. The drugs were chosen for hepatic artery infusion according to the individual chemosensitivity of tumor biopsies in the human tumor colony-forming assay (HTCA). In vitro HTCA sensitivity correlated with complete response (CR) + partial response (PR) + no change (NC) 93% of the time and with CR + PR 55% of the time. The test sensitivity was 90%, and the specificity was 67% for CR + PR + NC versus progressive disease (PD), whereas the sensitivity and specificity were 89% and 28%, respectively, for CR + PR versus NC + PD. The overall predictive accuracy of the test was 86% for CR + PR + NC versus PD and 58% for CR + PR versus NC + PD. Overall, 83% of this heterogenous patient group with various tumors achieved CR + PR + NC and a 50% clinical response (CR + PR). In vitro-sensitive patients showed a significantly lower intrahepatic progression rate (7% PD) than in vitro-resistant patients (57%; P < 0.05). These results indicate that the HTCA could identify active drugs for individualized hepatic artery infusion, and patients may profit from the use of in vitro-sensitive drugs.