[Pancreatic cancer. The relative importance of neoadjuvant therapy]

Neoadjuvant radiochemotherapy in patients suffering from pancreatic cancer is presently not well established. Neoadjuvant radiochemotherapy is recommended to be applied in 5-8 weeks. The full dose of radiotherapy is between 50 and 54 Gy with 5FU used as radiosensitator. In patients with resectable pancreatic cancer, particularly in UICC-stage II neoadjuvant radiochemotherapy, this results in an improvement in survival: the median survival is between 15 and 30 months. In about 15% of the patients with resectable pancreatic cancer (UICC I-III), neoadjuvant radiochemotherapy results in downstaging. In combination with a R0-resection,neoadjuvant radiochemotherapy effects a reduction of local recurrence. Results from controlled clinical trials are necessary to objectify the benefits of neoadjuvant radiochemotherapy.

Endoscopic mucosal resection for advanced non-polypoid colorectal adenoma and early stage carcinoma

PURPOSE

Endoscopic mucosal resection (EMR) techniques were evaluated in the treatment of flat and sessile colorectal neoplasm.

PATIENTS AND METHODS

Fifty-seven patients (32 female, 25 male) with non-polypoid colorectal lesions (n = 71, size >or= 10 mm) were included in the study. Tumor location, shape, size, and depth (in malignant lesions) were determined by endoscopy and endoscopic ultrasound. EMR was performed using snare resection, endoscopic aspiration mucosectomy, or EMR using a cap-fitted endoscope.

RESULTS

Lesion size ranged from 10 to 50 mm. Complete resection was achieved in 59 of 61 benign and 6 of 8 malignant tumors. Thirty-five tumors were excised in one segment and 34 tumors in piecemeal technique. Pathological examination of neoplasm treated by EMR showed adenoma in 61 and early-stage carcinoma in 8 cases. Because of the non-lifting sign, 2 of 71 tumors were not treated endoscopically and referred to surgical resection revealing a T2 adenocarcinoma in both cases. Resection was incomplete in 2 of 61 adenomas with histological positive resection margin. Complications occurred in 2 patients, with 1 bleeding treated endoscopically and 1 perforation treated by surgery. Local recurrence was observed in 2 of 59 completely resected adenomas and in none of 6 early-stage carcinomas during a mean follow-up of 18 months (range 6 to 30 months).

CONCLUSION

Advanced non-polypoid colorectal adenomas and early-stage carcinomas can be safely and effectively resected by endoscopic mucosal resection.

Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy

BACKGROUND

Gastrointestinal (GI) tract surgeons were challenged with the development of two revolutionary surgical specialities: laparoscopic and endoscopic surgery. Minimal access surgery currently is the surgical speciality with the greatest impact on patient care. Regarding the competitive treatment methods (open, laparoscopic, and intraluminal endoscopic management), each new treatment must be evaluated on the evidence of the patient's benefit, surgical morbidity, short- and long-term outcome, cost effectiveness and maintenance of quality of life.

METHODS

On the basis of randomized clinical trials, minimal access surgery results in reduced postoperative pain, reduced early postoperative analgetic medication, reduced frequency of systemic inflammatory response syndrome and systemic complications, early restoration of normal bowel function, and minimalization of wounds and skin scars. Among the well-established laparoscopic procedures, laparoscopic cholecystectomy has been convincingly demonstrated as superior to open cholecystectomy on the basis of controlled clinical trials. Superior benefit in favor of laparoscopic hernia repair has been demonstrated only regarding a lower level of pain, a higher level of physical activity, and earlier return to work. However, in terms of operating time and costs, open repair without mesh has benefits. Laparoscopic appendectomy offers benefits in terms of pain reduction, faster postoperative recovery, and lower incidence of wound infections, but has major drawbacks with regard to longer operating time, higher local complication rates, and significantly higher costs for total hospitalization. A cost study group concluded from a randomized clinical trial that only minimal short-term quality-of-life benefits were found for laparoscopically assisted colon resection, as compared with standard open colectomy, for colon cancer. On the basis of controlled clinical trials, there is only a little doubt that the laparoscopic approach is currently the operative treatment of choice for gastroesophageal reflux compliance. Endoscopic intraluminal techniques are increasingly important for minimalization of surgical treatment. For ulcer bleedings, endoscopic treatment is the established first choice. A major old and new challenge for GI tract surgeons is the intraluminal endoscopic approach to lesions. For neoplastic lesion in the esophagus (> 2 cm, mucosa restricted), Barrett's epithelium, early gastric cancer, adenoma of the ampulla of Vater, T1+, TIM lesion of the large bowel, T1 cancer of the rectum, intraluminal endoscopic treatment methods are increasingly replacing open surgical resection or even a laparoscopic technique. The surgeon must be aware that many of the local surgical complications, particularly those of GI tract anastomoses, are managed by endoscopic techniques.

CONCLUSIONS

The GI tract surgeon must accumulate competent endoscopic experience. His responsibility for GI diseases focuses on surgical treatment using minimal access surgical techniques including surgical endoscopy in preoperative, intraoperative, and postoperative settings. This major assignment is a challenge not only for GI tract surgeons in the near future.

Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome

BACKGROUND

Pancreatic injury is a dangerous complication in multiple injury, and experience with its diagnosis and treatment is usually limited.

METHOD

Retrospective analysis of 3,840 patients admitted after multiple trauma from January 1, 1982, until May 31, 2000.

RESULTS

A laparotomy was performed in 121 cases (3.15%) due to suspected intra-abdominal lesion. 32% of the patients (39/121) had a pancreatic lesion; 23% (9/39) had a rupture of the major pancreatic duct. Primary laparotomy was performed in 72% of the patients (28/39). Superficial lesions were treated by explorative laparotomy alone (n = 7), debridement and external drainage (n = 20), or necrosectomy and lavage (n = 3). Complex pancreatic lesions were treated by pancreatojejunostomies (n = 5), pancreatic left resections (n = 2), or exploration alone (n = 2). 8 of 39 patients died (20%), 4 intraoperatively. Of the surviving 35 patients, a pancreas-associated complication developed in 8 patients (23%): pancreatic abscesses (n = 4), traumatic pancreatitis (n = 3), pancreatic fistulas (n = 2), and pseudocysts (n = 2).

CONCLUSIONS

Pancreatic injury is an infrequent but dangerous complication in severe trauma. Superficial lesions not affecting the major pancreatic duct can be managed by debridement and external drainage. If the major pancreatic duct is ruptured, organ-preserving, complex reconstructive procedures are necessary. When diagnosed timely and treated according to severity and overall situation, pancreatic injuries have an acceptable morbidity, but usually a high mortality.

Expression of the IIIc variant of FGF receptor-1 confers mitogenic responsiveness to heparin and FGF-5 in TAKA-1 pancreatic ductal cells

BACKGROUND

Fibroblast growth factors (FGFs) contribute to angiogenesis and mitogenesis by binding to tyrosine kinase receptors termed FGF receptors (FGFRs). FGF-5 is a secreted FGF that is believed to preferentially act via the IIIc splice variant of FGFR-1. Human pancreatic ductal carcinoma cells express FGF-5 and FGFR-1IIIc, implying a potential for autocrine growth modulation.

AIM

In this study we investigated the importance of FGFR-1 IIIc expression for FGF-5 mitogenic signaling in a pancreatic ductal cell line.

METHODS

A cDNA encoding FGFR-1 IIIc was expressed in the well-differentiated TAKA-1 Syrian hamster pancreatic ductal cell line.

RESULTS

TAKA-1 cells secrete FGF-5, but were found not to express FGFR-1 and to be unresponsive to exogenous FGF-5. In contrast, TAKA-1 clones expressing FGFR-1 IIIc were growth stimulated in the presence of FGF-5 and displayed enhanced mitogen-activated protein kinase (MAPK) activity in the presence of FGF-5. PD98059, an inhibitor of this pathway, inhibited FGF-5-induced growth in these clones.

CONCLUSION

Our data demonstrate that FGFR-1 IIIc can mediate FGF-5-induced mitogenesis via the MAPK pathway in pancreatic ductal cells, and suggest that expression of FGFR-1 IIIc in conjunction with FGF-5 may contribute to the pathobiology of human pancreatic cancer.

Management of patients with extended pancreatic necrosis

BACKGROUND

Extended pancreatic necrosis pose a considerable therapeutic problem in patients with necrotizing pancreatitis.

AIM

Factors that limit conservative treatment in patients with extended pancreatic necrosis were analyzed.

METHODS

The clinical course of 61 patients with an extent of necrosis of more than 50% of the gland (according to contrast-enhanced CT scan) were analysed with special regard to systemic complications. Indications for surgical treatment were either persistent organ failure or pancreatic infection.

RESULTS

10 patients were managed by conservative treatment, 51 (84%) patients underwent operation. Indications for surgery were sepsis with or without organ failure in 17 patients, persistent organ failure in another 17 patients, persistent SIRS in 13 patients and local complications in 4 patients. Pancreatic infection was present in 25 patients. The incidence of systemic complications did not differ between infected and sterile necrosis, but they occurred earlier in sterile necrosis.

CONCLUSIONS

Persistent organ failure is limiting conservative treatment during the early course in patients with sterile necrosis. The latter course is characterized by a high incidence of pancreatic infection and septic organ failure.

Acute pancreatitis in transgenic mice expressing human group IIA phospholipase A2

INTRODUCTION

There is circumstantial and contradictory evidence of the role of group IIA phospholipase A2 (PLA2) in acute pancreatitis.

AIM

To examine the severity of acute experimental pancreatitis in transgenic mice expressing human PLA2 compared with mice not expressing PLA2.

METHODS

The study involved 12 young female CB57/bl mice not expressing group IIA PLA2 (wild-type mice) and 12 transgenic female CB57/bl mice expressing human group IIA PLA2 (transgenic mice). A choline-deficient, 0.5% ethionine-supplemented diet induced acute pancreatitis for 72 hours after 12 hours of fasting. Mice were killed 4 and 10 days after induction of acute pancreatitis. Pancreas, lung, kidney, and liver were examined histologically, and apoptosis in pancreas and liver was evaluated by DNA nick-end labeling (TUNEL).

RESULTS

On day 4, there were no significant differences in pancreatic apoptosis or total pancreatitis score. Liver damage was similar in both groups. On day 10, pancreatic damage was less but apoptosis more severe than on day 4, and neither hepatic damage nor apoptosis was seen. All mice expressing human group IIA PLA2 but none of the mice not expressing human group IIA PLA2 had marked pancreatic fibrosis. No significant pulmonary or renal damage was found at any time.

CONCLUSION

Pancreatitis in mice expressing human group IIA PLA2 is not more severe than in normal mice. Expression of group IIA PLA2 per se is not a major determinant of severity in experimental acute pancreatitis.

IIIc isoform of fibroblast growth factor receptor 1 is overexpressed in human pancreatic cancer and enhances tumorigenicity of hamster ductal cells

BACKGROUND & AIMS

Fibroblast growth factors (FGFs) are mitogenic polypeptides that signal via FGF receptors (FGFRs). Pancreatic ductal adenocarcinomas (PDACs) overexpress multiple FGFs, implying a potential for growth modulation. In this study we investigated the importance of the IIIc splice variant of FGFR-1 (FGFR-1 IIIc) in PDAC.

METHODS

Expression of FGFR-1 IIIc was determined by a ribonuclease protection assay in pancreatic cancer cell lines and in tissues. In situ hybridization was used to localize FGFR-1 IIIc messenger RNA (mRNA) in pancreatic tissues. A cDNA encoding FGFR-1 IIIc was stably transfected into the well-differentiated TAKA-1 pancreatic ductal cell line that is not responsive to FGF5 and does not express FGFR-1.

RESULTS

FGFR-1 IIIc was expressed in 5 of 7 pancreatic cancer cell lines and in the majority of the cancer cells in 4 of 7 PDAC samples. In vitro, TAKA-1 cells stably transfected with FGFR-1 IIIc exhibited increased basal growth; enhanced basal tyrosine phosphorylation of FGFR substrate-2 (FRS2), Shc, and phospholipase Cgamma; and increased activation of mitogen-activated protein kinase (MAPK). PD98059, an inhibitor of MAPK, suppressed the basal growth of parental and transfected clones, but the effect was more marked in clones expressing FGFR-1 IIIc. In vivo, tumor formation in nude mice was dramatically enhanced with FGFR-1 IIIc transfected (20 of 20) in comparison with sham transfected (0 of 10) cells.

CONCLUSIONS

Our data indicate that FGFR-1 IIIc is expressed in human pancreatic cancer cells, promotes mitogenic signaling via the FRS2-MAPK pathway, and has the potential to enhance pancreatic ductal cell transformation.

Association of time to recurrence with thymidylate synthase and dihydropyrimidine dehydrogenase mRNA expression in stage II and III colorectal cancer

Patients with International Union Against Cancer (UICC) stage IIb and III colon cancer and stage II and III rectal cancer may receive adjuvant chemotherapy with 5-fluorouracil (5-FU). High levels of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) have been associated with resistance to 5-FU in advanced colorectal cancer. The aim of this study was to investigate the association of TS and DPD mRNA levels with recurrence-free survival in patients with colorectal cancer who are receiving adjuvant 5-FU-based chemotherapy. TS and DPD mRNA quantitation was retrospectively performed in primary colorectal cancer specimens from patients receiving adjuvant 5-FU using a reverse transcription- polymerase chain reaction technique. The median TS mRNA level in patients with a recurrence (n = 142) was 0.68, and in patients without a recurrence (n = 206) the median level was 0.80 (P < 0.01). Patients with a recurrence who had a low TS level (TS < or = 0.9; n = 102) had a median recurrence-free survival of 18 months (range 3.0 to 54 months), and those with a high TS level (TS > 0.9; n = 40) had a median recurrence-free survival of 11 months (range 1.7 to 53 months; P = 0.0024). There was no difference in the median recurrence-free survival of patients with low and high DPD mRNA levels. The TS mRNA level may be a useful marker to predict the time to recurrence in patients with colorectal cancer who are receiving adjuvant 5-FU treatment.

Identification of tobacco-derived compounds in human pancreatic juice

Cancer of the pancreas is the fourth leading cause of cancer mortality in the USA with an estimated 28 900 deaths in 2001. Several factors have been implicated in the etiology of this disease. However, at present, only cigarette smoking has been positively associated with pancreatic cancer. It is our working hypothesis that tobacco-derived compounds can be delivered to the pancreas where, upon metabolic activation, they can initiate carcinogenesis. Our current investigation was conducted to determine whether cotinine and tobacco-specific nitrosamines (TSNA) are present in human pancreatic juice. Smoking status was assessed by the determination of levels of urinary cotinine and was further supported by quantifying nicotine in hair. The TSNA were extracted from the pancreatic juice of 18 smokers and 9 nonsmokers by supercritical carbon dioxide that contained 10% methanol. The extracts were analyzed for TSNA, namely, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN), by gas chromatography with mass spectrometric detection using a selected ion monitoring technique (GC-SIM-MS). Twenty-three extracts of human pancreatic juice were also analyzed for the presence of the NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) by GC-SIM-MS and by gas chromatography interfaced wit a thermal energy analyzer (GC-TEA; TEA, a nitrosamine-specific detector). Cotinine was detected in all analyzed samples of pancreatic juice from smokers (129 +/- 150 ng/mL juice; mean +/- standard deviation) and was present in only two of the nine samples of pancreatic juice from nonsmokers. Its levels in these two samples were 7 and 9 ng/mL juice. NNK was detected in 15 of 18 samples (83%) from smokers at levels from 1.37 to 604 ng/mL pancreatic juice. In nine samples of pancreatic juice from nonsmokers, NNK ranged from not detected (in three samples) to 96.8 ng/mL juice. In pancreatic juice from smokers the mean level of NNK (88.7 +/- 161 ng/mL juice) was significantly higher (p < 0.04) than in that from nonsmokers (12.4 +/- 31.7 ng/mL juice). In addition to NNK, NNN was found in two samples of pancreatic juice of smokers at levels of 68.1 and 242 ng/mL juice; NNN was not detected in any other sample. NNAL was present in 8 of 14 pancreatic juice samples (57%) from smokers and in three of nine samples (33%) from nonsmokers. This research presents preliminary data that supports the hypothesis that pancreatic tissue is exposed to TSNA and that they may be important contributors to pancreatic carcinogenesis in humans.

Serum amyloid A is a better early predictor of severity than C-reactive protein in acute pancreatitis

BACKGROUND

Serum amyloid A (SAA) is an early and sensitive marker of the extent of tissue trauma and inflammation. The aim of this study was to compare the early prognostic accuracy of SAA with that of serum C-reactive protein (CRP) in acute pancreatitis.

METHODS

In a prospective multicentre trial, plasma SAA and CRP levels were measured in patients with severe and mild acute pancreatitis, and in a control group with acute abdominal pain. Plasma samples were collected on admission and at 6-h intervals for 48 h, every 12 h between 48 and 72 h, then daily for 5 days. Plasma SAA was measured by a new enzyme-linked immunosorbent assay and CRP was measured by immunoturbidometry.

RESULTS

There were 137 patients with mild and 35 with severe acute pancreatitis, and 74 control patients. SAA levels were significantly higher in patients with severe acute pancreatitis than in those with mild acute pancreatitis, on admission, at 24 h or less after symptom onset, and subsequently. Whereas plasma CRP concentration was also significantly higher in patients with severe acute pancreatitis on admission, it failed to distinguish mild from severe acute pancreatitis until 30-36 h after symptom onset. SAA levels predicted severity (sensitivity 67 per cent, specificity 70 per cent, negative predictive value 89 per cent, mean(s.d.) area under curve 0.7(0.05)) significantly better than CRP (57 per cent, 60 per cent, 84 per cent, 0.59(0.06) respectively) on admission (P = 0.02) and at 24 h following symptom onset (area under curve 0.65(0.09) versus 0.58(0.09) respectively; P < or = 0.02).

CONCLUSION

Plasma SAA concentration is an early marker of severity in acute pancreatitis and is superior to CRP estimation on hospital admission and at 24 h or less after symptom onset. This study suggests that plasma SAA concentration is clinically useful, with the potential to replace CRP in the management of acute pancreatitis.

[Infected necroses and pancreatic abscess: surgical therapy]

Infected pancreatic necrosis and pancreatic abscesses are severe complications of necrotizing pancreatitis. Compared to infected necrosis, pancreatic abscess is associated with lower mortality. Surgical treatment is the current standard. Necrosectomy is performed as a single-step operation in combination with postoperative drainage/lavage or as scheduled reoperation. In selected cases, pancreatic abscesses can be successfully drained by percutaneous interventional drainage. Mortality in infected necrosis is 20-30% and 5-10% in patients with pancreatic abscess.

Characteristics of infection with Candida species in patients with necrotizing pancreatitis

This study focuses on the relevance of Candida infection (albicans and non-albicans) in patients with necrotizing pancreatitis. Altogether, 92 patients with infected pancreatic necrosis were reviewed for Candida infection. All patients underwent surgical necrosectomy for infected pancreatic necrosis. Data from patients with Candida growth in intraoperative smears were compared to those obtained from patients without Candida infection. There were 22 patients (24%) with Candida infection. Patients with or without Candida infection were comparable regarding age, gender, etiology, and severity scores at admission. Candida patients suffered a higher mortality (64% vs.19%, p = 0.0001) and experienced more systemic complications (3.2 +/- 1.6 vs. 2.1 +/- 1.4; p= 0.004) than patients without Candida. Preoperative antibiotics were given significantly longer prior to Candida infection (19.0 +/- 13.2 vs. 6.4 +/- 10.3 days; p < 0.0001). With regard to the concomitant spectrum of bacteria, solitary gram-negative infection was rare in Candida patients (5% vs. 43%, p =0.0006). The presence of Candida in patients with infected pancreatic necrosis is associated with increased mortality. Our data provide evidence that application of antibiotics contributes to the development of Candida infection and to changes in the bacterial spectrum of infected necrosis with an increase in the incidence of gram-positive infection.

NSC-631570 (Ukrain) in the palliative treatment of pancreatic cancer. Results of a phase II trial

BACKGROUND

NSC-631570 (Ukrain) is a semisynthetic compound of thiophosphoric acid and the alkaloid chelidonine from the plant Chelidonium majus. It has been used in complementary herbal medicine for more than 20 years for the treatment of benign and malignant tumors.

PATIENTS/METHODS

Between August 1999 and June 2001, 90 patients with histologically proven unresectable pancreatic cancer were randomized in a monocentric, controlled, randomized study. Patients in arm A received 1000 mg gemcitabine/m2, those in arm B received 20 mg NSC-631570, and those in arm C received 1000 mg gemcitabine/m2 followed by 20 mg NSC-631570 weekly. End point of the study was overall survival.

RESULTS

In all three arms therapy was well tolerated and toxicity was moderate. At the first re-evaluation in arm A 32%, in arm B 75%, and in arm C 82% showed no change or partial remission according to WHO criteria (arm A versus arm B: P<0.01, arm A versus arm C: P<0.001). Median survival according to Kaplan-Meier analysis was in arm A 5.2 months, in arm B 7.9 months, and in arm C 10.4 months (arm A versus arm B: P<0.01, arm A versus arm C: P<0.01). Actuarial survival rates after 6 months were 26%, 65% and 74% in arms A B and C, respectively (arm A versus arm B: P<0.05, arm A versus arm C P<0.01).

CONCLUSION

We could show that in unresectable advanced pancreatic cancer, NSC-631570 alone and in combination with gemcitabine nearly doubled the median survival times in patients suffering from advanced pancreatic cancer.

Surgery, radio- and chemotherapy for multimodal treatment of rectal cancer

The possibilities and results of multimodal treatment in rectal cancer were reviewed with respect to the results of surgical treatment only. Based on the results of 4 studies, reducing local relapse rates and increasing long term survival rates significantly, postoperative radiochemotherapy (RCT) + chemotherapy (CT) should remain the recommended standard for R0 resected UICC II and III rectal cancers. The addition of RT to adjuvant CT reduces local relapses without significant impact on survival (NSABP R-02). Vice versa, the addition of CT to RT or an improved CT in the RCT-concept prolongs survival. Preoperative neoadjuvant radiotherapy (RT) reduced local relapse rates in 9 studies, and extended survival in one study that evaluated all eligible patients. Preoperative RT reduced local relapse rates in addition to total mesorectal excision (TME) but did not extend survival. The preoperative RCT + CT downstages resectable and nonresectable tumors and induces a higher sphincter preservation rate. Phase III data justifying its routine use in all UICC II + III stages are not yet available. This treatment may be routinely applied in nonresectable primary tumors or local relapses. Preoperative RCT (or RT) may evolve as standard, if the patient selection is improved and postoperative morbidity and long term toxicity reduced. Intraoperative RT could be added to this concept or be used together with preoperative/postoperative RT at the same indications. Postoperative adjuvant RT reduced local relapses significantly in a single trial, and no impact on survival time is reported. Since postoperative RT is inferior to preoperative RT, this treatment cannot be recommended, if RT is chosen as a single treatment modality in adjunction to surgery. The results of local tumor excisions may be improved with pre- or postoperative RCT + CT. In the future, multimodal treatment of rectal cancer might be more effective, if individualized according to prognostic factors.

Serum amyloid A is a better early predictor of severity than C-reactive protein in acute pancreatitis

BACKGROUND

Serum amyloid A (SAA) is an early and sensitive marker of the extent of tissue trauma and inflammation. The aim of this study was to compare the early prognostic accuracy of SAA with that of serum C-reactive protein (CRP) in acute pancreatitis.

METHODS

In a prospective multicentre trial, plasma SAA and CRP levels were measured in patients with severe and mild acute pancreatitis, and in a control group with acute abdominal pain. Plasma samples were collected on admission and at 6-h intervals for 48 h, every 12 h between 48 and 72 h, then daily for 5 days. Plasma SAA was measured by a new enzyme-linked immunosorbent assay and CRP was measured by immunoturbidometry.

RESULTS

There were 137 patients with mild and 35 with severe acute pancreatitis, and 74 control patients. SAA levels were significantly higher in patients with severe acute pancreatitis than in those with mild acute pancreatitis, on admission, at 24 h or less after symptom onset, and subsequently. Whereas plasma CRP concentration was also significantly higher in patients with severe acute pancreatitis on admission, it failed to distinguish mild from severe acute pancreatitis until 30-36 h after symptom onset. SAA levels predicted severity (sensitivity 67 per cent, specificity 70 per cent, negative predictive value 89 per cent, mean(s.d.) area under curve 0.7(0.05)) significantly better than CRP (57 per cent, 60 per cent, 84 per cent, 0.59(0.06) respectively) on admission (P = 0.02) and at 24 h following symptom onset (area under curve 0.65(0.09) versus 0.58(0.09) respectively; P < or = 0.02).

CONCLUSION

Plasma SAA concentration is an early marker of severity in acute pancreatitis and is superior to CRP estimation on hospital admission and at 24 h or less after symptom onset. This study suggests that plasma SAA concentration is clinically useful, with the potential to replace CRP in the management of acute pancreatitis.

Pancreatic cancer: who benefits from curative resection?

Surgical resection is the only chance for cure of pancreatic cancer. Unfortunately, the majority of patients have grossly unresectable disease. Patients with stage I or II disease according to the criteria of the International Union Against Cancer (UICC) should be considered for potentially curative surgery. The goal of surgery is to remove the entire tumour with no residual disease (oncological R0 resection), which requires extensive resection of the surrounding tissues. Even if lymph nodes are histologically free of disease, molecular biological techniques reveal infiltration with cancer cells in 50% of cases. Therefore, extensive local resection combined with radical resection of lymphatic tissue, including lymph nodes around the head of the pancreas, retroperitoneal tissue and neural plexus around the great vessels, affords a longer median survival time than standard resection alone. Even patients with UICC stage III disease can undergo aggressive surgical treatment, but their chances for long term survival are low. Some patients develop severe diarrhea after circumferential removal of nerve tissue around the superior mesenteric artery. Adjuvant radiochemotherapy also provides a modest prolongation of survival. Despite these advances, the prognosis for pancreatic cancer is still poor, and spread of tumour within the peritoneum and to the liver is common postoperatively.

Interaction of fibronectin and aggregation substance promotes adherence of Enterococcus faecalis to human colon

This in vitro study investigates the interaction between aggregation substance (AS), a virulence factor of Enterococcus faecalis, and colonic mucosal fibronectin in normal colon and colon from patients with Crohn's disease. Fibronectin was found to be overexpressed in Crohn's disease compared to normal colon. Compared to E. faecalis OG1X:pAM944 (AS-negative), E. faecalis OG1X:pAM721 (expressing AS) showed a significantly enhanced adhesion to human colonic mucosa in normal colon and in colon from patients with Crohn's disease. Double-staining of fibronectin and AS-positive enterococci showed that colocalization of bacteria and fibronectin was significantly more frequent in Crohn's disease than in normal colon. Preincubation of bacteria with soluble fibronectin caused a significant reduction in the adherence to fibronectin. In conclusion, the interaction between AS and fibronectin plays is an important factor that mediates adhesion of Enterococcus faecalis to colonic mucosa. This might be one of the mechanisms responsible for bacterial translocation of Enterococcus faecalis.

Duodenum-preserving pancreatic head resection leads to relief of common bile duct stenosis

BACKGROUND

Common bile duct stenosis (CBDS) is one of the most frequent complications in chronic pancreatitis with inflammatory mass in the head of the pancreas (IMH).

METHODS

A total of 474 patients who underwent duodenum-preserving pancreatic head resection (DPPHR) between 1982 and 1998 were reevaluated; 219 patients (46%) with a mean duration of the disease of 45 months had a radiologically proven CBDS.

RESULTS

One patient (0.5%) died of septic complications in the early postoperative course, 15 patients (6.8%) had to be reoperated on for complications. A follow-up investigation of 143 patients (92%) revealed a late mortality of 12%; no patient died of biliary complications. Seventy-five percent of the patients were completely free of pain, and 85% of the patients had a constant or even increasing body weight.

CONCLUSIONS

The high percentage of pain-free patients with improved physical status and economical rehabilitation demonstrates the improvement of the quality of life after DPPHR for complicated chronic pancreatitis.

Inhibition of nitric oxide synthase does not influence urinary nitrite plus nitrate excretion after renal ischemic injury

BACKGROUND AND AIMS

Whether renal nitric oxide production caused by ischemia/reperfusion (I/R) influences the urinary excretion of nitric oxide (NO) metabolites (nitrite and nitrate) is far from being elucidated. In the present study, we evaluated the role of NO synthase inhibition using N(G)-nitro- L-arginine methyl ester ( L-NAME) in a model of experimental renal I/R injury.

METHODS

Male Wistar rats were used in our experiments, and renal I/R injury was achieved after a 30-min occlusion of the bilateral renal artery followed by a 60-min period of reperfusion. Renal function including nitrite plus nitrate excretion and hemodynamics in reperfused kidneys were measured in the presence and absence of L-NAME.

RESULTS

Intravenous application of L-NAME (5 mg/kg body weight) resulted in a marked reduction of urine flow, renal plasma flow (0.7 +/- 0.3 ml/min), and the glomerular filtration rate (0.1 +/- 0.01 ml/min), but a significant increase in NO excretion (FENOx, 67.9 +/- 10.5%). In addition we found after L-NAME injection a significant increase of the fractional excretion of sodium (FENa, 49.3 +/- 7.7%) and lithium (FELi, 70.2 +/- 1.6%), as well as the renal vascular resistance compared with animals with renal I/R but non-treated with L-NAME ( P<0.001). Furthermore, we observed a high correlation between FENOx and FELi (r(2)=0.80, P<0.01).

CONCLUSION

Our results suggest that renal excretion of NO derivatives is not influenced by NO production during renal I/R injury, although NO contributes to the tubular transport capacity in the ischemia/reperfused kidney.

Therapeutic application of caspase 1/interleukin-1beta-converting enzyme inhibitor decreases the death rate in severe acute experimental pancreatitis

OBJECTIVE

To assess the effect of therapeutic inhibition of interleukin 1beta-converting enzyme (ICE) in an experimental model of severe acute pancreatitis (SAP).

SUMMARY BACKGROUND DATA

Several lines of evidence suggest that cytokines activated by ICE play an instrumental role in the course of acute pancreatitis. Recent studies have shown that pharmacologic or genetic blockade of ICE significantly ameliorates the overall severity of and the death rate in SAP.

METHODS

Severe acute pancreatitis was induced by infusion of 5% sodium taurocholate in Wistar rats. A new, highly selective, irreversible inhibitor of ICE was intraperitoneally applied at a dosage of 0.25 mg every 12 hours. Control animals in group 1 received treatment with saline; in group 2 rats, ICE inhibition was started 6 hours after the onset of pancreatitis; and in group 3 rats, ICE inhibition was started 12 hours after the onset of pancreatitis. After a 7-day observation period, surviving rats were killed and blood, plasma, pancreas, lung, and liver were used for subsequent analysis.

RESULTS

Inhibition of ICE decreased the 7-day death rate from 87.5% to 38.9% irrespective whether treatment was started 6 hours or 12 hours after induction of SAP. Morphometric analysis revealed a significant reduction of acinar cell necrosis in both treated groups, whereas pancreatitis-associated pulmonary and hepatic damage was uniformly low and not influenced by ICE inhibition. Tissue myeloperoxidase concentrations were dramatically decreased in the pancreas and the lung after either regimen of ICE inhibitor treatment. In contrast to lung and liver, marked upregulation of interleukin 1beta, tumor necrosis factor alpha, and ICE mRNA was observed in the pancreas, with levels of interleukin 1beta and tumor necrosis factor alpha being reduced in ICE-inhibited animals. Compared with nontreated rats, plasma amylase levels were higher in both treatment groups, whereas lipase and hematocrit showed no difference. Changes of the differential white blood count including neutrophils, lymphocytes, and monocytes were attenuated in both groups after ICE inhibitor treatment.

CONCLUSIONS

Pharmacologic inhibition of ICE significantly improves the overall severity of and the death rate in SAP. A substantial reduction of neutrophil-mediated tissue injury in pancreas and lung seems to contribute to the beneficial effects of this approach. Moreover, ICE inhibition is still effective after a therapeutic window of 12 hours. Based on the current findings, future studies on the clinical application of ICE-inhibiting substances in acute pancreatitis seem to be promising.

Regional chemotherapy of nonresectable colorectal liver metastases with mitoxantrone, 5-fluorouracil, folinic acid, and mitomycin C may prolong survival

BACKGROUND

Regional chemotherapy of isolated, nonresectable colorectal liver metastases (CRLMs) by hepatic artery infusion (HAI) has the advantages of high response rates and the possibility of downstaging and resection of CRLMs. 5-Fluorodeoxyuridine (5-FUDR) has been the drug studied in most Phase II and III trials. The meta-analysis of the Phase III trials comparing HAI with systemic or supportive therapy confirmed an advantage for response and even survival for HAI. Hepatic artery infusion with 5-FUDR, however, is hepatotoxic, inducing sclerosing cholangitis (SC). The authors have introduced 5-fluorouracil (5-FU) with folinic acid for HAI and found equal effectivity but no SC when compared with HAI with 5-FUDR. Now, they report a new combination chemotherapy protocol based on HAI with 5-FU with FA and on in vitro Phase II studies suggesting mitoxantrone and mitomycin C as active drugs for HAI in CRLM. PATIENTS AND METHODS Between February 1993 and August 2000, 63 patients with CRLM were treated with HAI using mitoxantrone, 5-FU with FA, and mitomycin C (MFFM) via port catheters with a protocol planing up to 11 cycles of treatment. Toxicity and response were analyzed according to World Health Organization (WHO) criteria, and survival was analyzed according to Kaplan-Meier. All patients were treated with more than two HAI cycles.

RESULTS

The objective response rate (complete remission and partial remission) was 54% and primary intrahepatic progression (progressive disease) occurred in 4.8%, whereas in 41.3% of the patients the intrahepatic disease was evaluated as no change. Median survival times from the first diagnosis of CRLM or start of HAI were 25.7 months and 23.7 months, respectively, and 7 patients lived longer than 40 months. Grade 3 toxicity according to WHO occurred in 34.9%, and Grade 4 occurred in 3.2%. No toxic death or SC occurred.

CONCLUSIONS

Our new HAI protocol with MFFM seems to be superior to HAI with 5-FUDR, 5-FU with FA, and systemic chemotherapy with 5-FU and FA at acceptable toxicity. Currently, HAI with MFFM is compared with systemic chemotherapy using 5-FU and FA intravenously in a randomized Phase III trial.