Duodenum-preserving resection of the head of the pancreas--an alternative to Whipple's procedure in chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas is a low-risk operation for patients with chronic pancreatitis. Subtotal resection of the head of the pancreas does not result in a significant diminishment in the exocrine and endocrine functions of the pancreas. Owing to the limited nature of the intervention, hospital and late mortality rates are low. More than 80% of the patients with CP have experienced long-lasting relief of pain after this procedure. In comparison with the Whipple operation duodenum-preserving resection of the head of the pancreas spares the patient a gastrectomy, a duodenectomy, and resection of the extrahepatic bile duct.

[Magnetic resonance tomography in orthotopic liver transplantation]

14 patients with orthotopic liver transplantation were prospectively studied with MR imaging. MR imaging demonstrated a perivascular collar surrounding central portal venous branches in 14 patients. The perivascular collar had low signal intensity on T1-weighted and high signal intensity on T2-weighted images. In 10 of the 14 patients, a perivascular collar was also observed around peripheral portal venous branches. The perivascular collar is probably caused by intraoperative interruption of hepatic lymph vessels and resultant impaired lymph drainage. It is a normal postoperative phenomenon in hepatic transplants. MR imaging is particularly useful in the distinction of postoperative hematoma from other intra- and extrahepatic fluid collections and may provide a noninvasive assessment of liver transplant rejection.

The duodenum preserving resection of the head of the pancreas (DPRHP) in patients with chronic pancreatitis and an inflammatory mass in the head. An alternative surgical technique to the Whipple operation

Since 1972, resection of the head of the pancreas with preservation of the duodenum has been carried out in 141 patients with chronic pancreatitis and an inflammatory mass in the head of the gland. One patient died in hospital (0.7%), and seven further patients died during the median follow-up period of 3.6 years (range 0.5-16). In contrast to the Whipple procedure, this operation spares the patient a gastric resection, a duodenectomy, and resection of the common bile duct. In terms of long lasting relief of pain and preservation of the endocrine function of the pancreas, the limited resection with preservation of the duodenum is highly effective and the mortality and late morbidity are low.

[Effect of liver passage on peripheral glucose and hormone concentrations in early postoperative enteral nutrition]

Early postoperative disorders of blood glucose homeostasis and its hormonal regulation do not allow a normal caloric enteral or parenteral substrate supply in this period. Eleven land pigs were investigated to find out how the surgical trauma of a partial gastrectomy influences the absorptive capacity of the small intestine and the hormonal regulation after intraduodenal administration of a glucose solution. We therefore conducted portal vein measurements to correlate the influence of the liver passage of early postoperative changes in blood glucose and hormonal levels. Our data show that neither the porto-arterial differences in blood glucose nor those in hormonal concentrations are significant. Therefore, we conclude that peripheral measurements can be used as good and reliable parameters for such investigations of absorption or hormonal regulation in the early postoperative period.

[Value of magnetic resonance tomography in Pancoast and other tumors with infiltration of the thoracic wall]

Twenty-two patients with intrathoracic malignancies and suspected Pancoast and "break-out" tumours were submitted to a comparative investigation using CT scanning and MRI to detect infiltration of the chest-wall. In the patients, the lesion had been confirmed at surgery, which revealed malignant infiltration in 19 cases, and excluded in filtration in 3 cases. In 14 out of 19 patients, the CT scan revealed tumourous involvement of the chest-wall, while in five out of 19 patients, no such involvement was detected. Using MR imaging, tumour infiltration was detected in all 19 patients. A reliable MR sign of tumour involvement was the detection of signal-intensive lesions within the chest-wall in T1-weighted images following the administration of Gd-DTPA, and in the T2-weighted images. In contrast, signal enhancement of the pleura was found both in tumour involvement and in inflammation. In suspected tumorous chest-wall invasion MR imaging can demonstrate tumour involvement of the chest-wall when CT is equivocal.

Der Einfluß einer enteralen und parenteralen Ernährung auf die Glukosetoleranz in der frühpostoperativen Phase

Wir untersuchten die unterschiedliche Erholung der gestörten Glukosetoleranz in der frühen postoperativen Phase in Abhängigkeit vom Weg der Substratzufuhr. Dazu wurden in einer randomisierten Studie 24 Patienten, die sich kolorectalen Resektionen unterziehen mußten, 2 Gruppen zugeteilt, die wir dann postoperativ jeweils 6 Tage enteral bzw. parenteral ernährten, Zur Prüfung der Glukosetoleranz führten wir einen enteralen Toleranztest präoperativ, am 1., 3. und 6. postoperativen Tag durch. Die Ergebnisse zeigen eine signifikante Verbesserung der Glukosetoleranz in der enteral ernährten Gruppe am 3. und 6. postoperativen Tag. Die Insulinkonzentrationen sind in dieser Gruppe am 3. postoperativen Tag signifikant, am 6. postoperativen Tag noch deutlich gegenüber der parenteralen Gruppe erhöht. Ähnlich verhalten sich auch die C-Peptid-Konzentrationen, die als Maß für die gesteigerte Insulinfreisetzung gelten können. Nach diesen Ergebnissen ist eine enterale Applikation von Glukose der parenteralen in der frühpostoperativen Phase signifikant überlegen.

Regional chemotherapy in liver metastases of colorectal carcinoma: monitoring with arterial computed tomography

Continuous chemotherapy was administered to 82 patients through the hepatic artery via Infusaid pumps. In order to obtain a primary status and to evaluate the success of therapy, the perfusion patterns of the liver and of the existing tumor masses in the liver were estimated by conducting arterial angiocomputed tomographies (AACTs) immediately after pump implantation of every 3 months thereafter. In 70% of the patients, findings showed both liver lobes to be homogeneously perfused, 24% demonstrated distinct inhomogeneities. The response of the latter cases should depend primarily on the efficacy of the administered cytostatic agent. Six percent of the patients showed selective perfusion of either the left or right hepatic lobe. In these cases, only the perfused liver regions exhibited stable disease or regression of the metastases, whereas the metastases of the nonperfused regions progressed. At 3-month follow-up, the majority of the patients (50-57%) showed homogeneous hepatic perfusion. Inhomogeneities were found in 26-36% of the patients, 12 patients demonstrated incomplete perfusion. There was no association between the perfusion patterns of the metastases or of the prechemotherapeutic liver involvement and the response of the metastases to regional chemotherapy. In regional chemotherapy, liver perfusion should be controlled both intraoperatively or directly postoperatively and during therapy.

Der Einfluß der Leberpassage auf die peripheren Glukose- und Hormonkonzentrationen bei frühpostoperativer enteraler Ernährung

An 11 Landschweinen wurde der Einfluß des Operationstraumas einer Magenkeilresektion auf die resorptive Kapazität des Dünndarmes und der hormonellen Regulation bei intraduodenaler Glukosegabe untersucht. Dabei wurde durch Pfortadermessungen der Einfluß der Leberpassage und die frühpostoperativen Veränderungen der Hormon- und Blutzuckerspiegel im peripheren und portalen Blut verglichen. Unsere Untersuchungen zeigen, daß sich in den portoarteriellen Differenzen weder im Blutzucker noch den Hormonkonzentrationen ein signifikanter Unterschied nachweisen läßt. Periphere Messungen dieser Größen können deshalb als verlässliche Parameter für Untersuchungen zur Resorption als auch zur hormonellen Regulation unmittelbar posttraumatisch benutzt werden.

[Malignant chest wall infiltration in MR: comparison with CT and surgical findings]

CT and MRI were performed on 19 patients with pleura related thoracic tumors with respect to the detection of chest-wall invasion. All patients underwent surgery, which confirmed malignant infiltration in 16 cases, while this was excluded in three. CT showed chest-wall invasion in 12/19 patients. MRI demonstrated tumorous involvement in 16 patients. A reliable pattern of chest-wall invasion in MRI were high signal intensity lesions within the chest-wall in the T2-weighted images. However, increased signal intensity of pleural structures was found in inflammatory as well as in malignant lesions. MRI can prove the presence of chest-wall invasion when CT is equivocal.

[Duration of the preventive use of antibiotics in colorectal surgery--single administration versus short-term prevention]

The effect of a combination of 4 g mezlocillin and 0.5 g metronidazole for the prophylaxis against infections in a one-shot dose immediately preoperatively compared to a short-time dose of 2 days given to 90 patients with resection of colorectal carcinoma was investigated in a prospective and randomized study. 6 patients developed a wound infection in the early postoperative phase; 4 of these infections (3 were severe, 1 was mild) occurred in the one-shot group and 2 in the short-time prophylaxis group. After more than 20 days postoperatively 3 late infections were observed which had a mild course (2 cases in the one-shot group, 1 case in the short-time prophylaxis group). All infections were localized in the sacral wound region in patients with abdominoperineal resection. The abdominal wounds healed per primam in each case. Besides those, 26 infections of the urinary tract were observed, which occurred significantly more often after the one-shot dose (40.9%) than with the short-time prophylaxis (18.6%). Intraoperative smears of the lumen of the bowels showed a remaining bacterial settlement. Besides Bacteroides species, especially Escherichia coli were found among the isolates. Moreover in some cases Clostridium, Klebsiella, Proteus and Pseudomonas could be identified. Smears of the site of operation (sacral/peritoneal cavity) were contaminated in over 50%, above all by Bacteroides species; besides those, E. coli were found most often. The subcutaneous smears showed a growth of the germs only in a few cases. Aerobic bacteria in 93.8%, anaerobic bacteria except for thetaiotaomicron and B. asaccharolyticus in 85.1%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Perioperative glucose resorption and hormonal reaction following intraduodenal glucose administration]

Early postoperative enteral nutrition has repeatedly been described in the literature but has not found its place yet in everyday clinical life. We conducted perioperative intraduodenal glucose tolerance tests in 12 patients with a healthy metabolism who had to undergo moderately severe abdominal surgery. Our results suggest that the resorption is still markedly delayed 12 h postoperatively and that the hormonal regulation is also essentially disturbed. Therefore, we believe that enteral nutrition in the early postoperative period is beneficial only more than 24 h after surgery.

Regional chemotherapy for hepatic metastases of colorectal carcinoma (continuous intraarterial versus continuous intraarterial/intravenous therapy). Results of a controlled clinical trial

Sixty-four patients with a biopsy diagnosis of colorectal cancer with liver metastases were treated with 5-fluorodeoxyuridine (FUDR) infusions. In a pilot study, the first 20 patients were given hepatic artery infusions of FUDR by implanted pumps. The remaining 44 patients were then randomized prospectively to compare the effectiveness of continuous hepatic artery and intravenous infusion of FUDR (IA/IV group; 21 patients) with hepatic artery infusion alone (IA group; 23 patients). A continuous 14-day infusion regimen of FUDR was applied each month. The dosage was 0.2 mg/kg/d of FUDR for the IA group and 0.3 mg/kg/d for the IA/IV group. The complete and partial response rates were each 50% in the pilot study and 52% and 48% in the IA and IA/IV randomized groups, respectively. Drug toxicities in the 64 patients included gastroenteritis (21%), chemical hepatitis (57%), and biliary sclerosis (25%). There was no difference in the toxicity of FUDR in the two randomized groups (P greater than 0.1). Extrahepatic spread of cancer during therapy was found in 61% (n = 14) of the IA group and 33% (n = 7) of the IA/IV group. There was no difference in survival between the randomized groups. The 64 patients were categorized into the following two groups according to their response to therapy: (1) responders (patients with complete or partial remission [n = 32]) or nonresponders (patients with stable disease or progression of metastases [n = 32]). The median survival time was 31 months for responders and 16 months for nonresponders (P less than 0.0001). Intraarterial FUDR infusion provided control of liver metastases. The combination of intraarterial and intravenous therapy seemed to prevent extrahepatic spread during therapy in most of the patients. Survival appeared to be significantly prolonged in patients with a regression of metastases.

[Imaging diagnosis of aggressive fibromatosis and the MRT-pathological correlation]

Aggressive fibromatoses (desmoid tumours) tend to grow in an infiltrative and destructive manner without metastases. Computed tomography of aggressive fibromatoses yields no uniform attenuation pattern. The tumours are typically isodense when no contrast medium is used and enhance clearly to hyperdense during infusion of contrast medium. In magnetic resonance tomography (MRT) a high signal (long T2) on T2-weighted pulse sequences as well as an accumulation of i.v. Gd-DTPA seems to be the characteristic appearance of aggressive fibromatoses, although different signal intensities can be seen. The MRT histopathologic correlation shows increasing signal intensities on T2-weighted sequences dependent on an increment in cellular content of the tumours. Only histopathological methods can provide a definite diagnosis.

[Effect of tumor size and lymph node status on the prognosis of pancreatic cancer]

Between 1982 and 1987 186 patients with a carcinoma of the pancreas underwent surgery. In 69 patients (37%) a resective surgical procedure was performed. In these patients, lymph node staging was conducted intraoperatively. The operative mortality of the resection was 4.3%. The median survival of the resected patients with papillary carcinoma was 21 months and of the patients with ductal pancreatic carcinoma 7 months. A correlation between survival time and frequency as well as localization of the lymph node attack could be established. Only patients in the TNM stage I of a ductal carcinoma appeared to have profited significantly from the resection compared to the palliative procedure.

[A new multislice gradient echo sequence for magnetic resonance tomography of the liver]

A multislice gradient echo sequence was developed for screening the liver and examined in studies on probands. This sequence is characterized by pronounced T1-weighting and low susceptibility to artifacts as well as a good contrast-to-noise ratio. Examination of the probands yielded suitable parameters for the repetition time, the delay echo, the excitation pulse angle and the number of data acquisitions. The optimized sequence yields, at a repetition time of 306 msec and an echo delay of 12 msec, 18 adjacent slices. With these measurement parameters an excitation pulse angle of 90 degrees was found to be adequate. Four data acquisitions (5.4 minutes measurement time) resulted in an effective reduction of motion artifacts. Compared with the T1-weighted spin echo sequences, the entire liver can be measured in half the time when using the multislice gradient echo sequence.

Perioperative Glukoseresorption und hormonelle Reaktion nach intraduodenaler Glukoseapplikation

Eine frühpostoperative enterale Ernährung wird in der Literatur immer wieder beschrieben, hat sich aber im klinischen Alltag nicht durchsetzen können. An 12 stoffwechselgesunden Patienten, die sich mittleren abdominalchirurgischen Operationen unterziehen muβten, führten wir perioperative intraduodenale Glukosebelastungen durch. Durch unsere Ergebnisse können wir zeigen, daβ die Resorption nach 12 h postoperativ noch deutlich verzögert und auch die hormonelle Regulation erheblich gestört ist. Eine enterale Ernährung in der frühpostoperativen Phase erscheint uns deshalb erst nach mehr als 24 h sinnvoll.

The penetration of antibiotics into human pancreas

In order to analyse the penetration of two antibiotics (mezlocillin and metronidazole) which cover the spectrum of microorganisms involved in pancreatic infection, we determined their concentration in pancreatic tissue, juice and cyst fluid in 16 patients undergoing pancreatic surgery. In addition, the external pancreatic fistula fluid of one patient was analysed for antibiotic concentration and bacterial counts during a seven-day treatment with mezlocillin, metronidazole and netilmicin (i.v.). Antibiotic concentrations were determined by HPLC between 16 and 210 (median 74) min after i.v. administration of 4 g mezlocillin and 500 mg metronidazole, respectively. The median concentration of mezlocillin was 23.2 (range: 3.1-37.4) mg/kg, 15.9 (range: 4.2-55.0) mg/l and 9.9 (range: 5.2-14.8) mg/l in pancreatic tissue, juice and cyst fluid, respectively. The median concentration of metronidazole was 5.1 (range: 1.8-13.0) mg/kg, 8.5 (range: 3.6-16.2) mg/l and 1.2 (0.9-1.4) mg/l in pancreatic tissue, juice and cyst fluid, respectively. From the fistula patient, seven different bacteria were cultured (five aerobic and two anaerobic isolates); their concentration in fistula fluid ranged from 10(5) to 10(7) CFU/ml. The bacteria sensitive for mezlocillin and metronidazole disappeared after four days of i.v. treatment, whereas the two isolates sensitive for netilmicin showed continuous growth seven days after i.v. treatment. The peak concentrations for mezlocillin, metronidazole and netilmicin in the fistula fluid were 6.8 mg/l, 5.6 mg/l and less than 0.1 mg/l, respectively.

'Entero-insular axis' and surgical trauma

To study the optimal means of postoperative energy supply, three glucose loads (5 g, 15 g, 40 g) were given via the enteral or the parenteral route before and immediately after abdominal surgery. Pre- and post-operatively, glucose and insulin concentrations were strongly dose-related after both kinds of administration. But the postoperative insulin concentrations were higher than the preoperative ones. Likewise, in both test situations the 'insulinogenic index' was significantly higher postoperatively than preoperatively. After the enteral glucose load, however, the index was 3 to 10 times higher than after the parenteral one. According to these results, even in the early postoperative period the enteral route of glucose administration is not only feasible but seems also to be superior to the parenteral one.

Hepatocellular carcinoma in type I glycogen storage disease

Patients suffering from Type I glycogen storage disease frequently develop hepatic tumors. Some of these were classified as carcinoma, with the majority of tumors representing benign adenomata. However, no evidence exists of malignant transformation of adenomata in these patients. Here, we describe the occurrence of a hepatocellular carcinoma in the adenomata-bearing liver of the elder of two sisters suffering from Type I glycogen storage disease at the age of 20 years, 6 years after the diagnosis had been made. Surprisingly, alpha-fetoprotein levels were normal throughout the entire course of this patient, whereas the younger sister had elevated levels despite the absence of malignant lesions. Thus, the clinical significance of alpha-fetoprotein remains unclear in both cases. Nocturnal feeding, although performed continuously over the 6 years after the diagnosis, had obviously failed to prevent the development of hepatic tumors in both patients.

The clinical relevance of tumor marker CEA, CA 19-9 in regional chemotherapy of hepatic metastases of colorectal carcinoma

Up to December 1986, 50 patients with documented hepatic metastases from colorectal carcinoma were treated with 5-fluoro-2-deoxyuridine (FUDR) using Infusaid pumps. The response of liver metastases to regional chemotherapy was studied by computerized tomography (CT) and carcino-embryonal antigen (CEA), and/or CA 19-9 antigen serum assays. Preoperative CEA values were pathological in 94% of the patients but only 48% had a pathological concentration of the antigen CA 19-9 of over 37 U/ml. The course of CEA and CA 19-9 in combination with the arterial angio-CT reflected the response of liver metastases to regional chemotherapy. A decrease or normalisation of CEA and CA 19-9 after the beginning of therapy is an indication of partial or complete remission of metastases (68% of the patients showed lowered CEA serum values). If the marker continues to rise in serum this is a danger signal of progression of liver metastases or of extrahepatic tumor spread if the tumor stage in the liver remains unchanged.

[Necrosectomy and bursa lavage in necrotizing pancreatitis. Results of a prospective clinical study]

In a prospectively performed clinical trial a surgical management protocol including necrosectomy and postoperative local lavage of the necrosis cavity and the omental bursa was applied in 95 patients with necrotizing pancreatitis. In 80% of them severe organ failures occurred preoperatively, in spite of intensive care treatment. The median value of early prognostic signs of these patients was 4.5. Intraoperatively 59% showed extended pancreatic necroses and 66% an extension of the necroses into extrapancreatic tissue structures; in 42% bacteria were detected in the necrotic material. After necrosectomy the postoperative local lavage was performed for an average period of 25 days with 8 1 of lavage fluid per 24 hours in median. The average intensive care period came to 7.0 days, the average postoperative hospital time was 60 days. The hospital mortality amounted to 8.4%. The advantage of this management protocol including necrosectomy and postoperative local lavage lies in the continuous emptying of vasoactive and toxic substances, germs and necrotic material.

[Magnetic resonance tomography (MRT) in bronchial cancer]

Comparative studies were made of 47 patients suffering from histologically and cytologically confirmed bronchial carcinoma, using CT and MRT respectively. CT examinations were performed before and after intravenous administration of contrast medium, whereas the MR examinations were conducted via EEG-triggered T1 and T2 marked SE sequences in the axial and coronary planes. Both methods were assessed in respect of tumour visualisation and documentation of tumour spread. Staging of tumour and lymph nodes yielded largely concurring results for CT and MRT. Exceptions were seen in 7 of 10 patients with malignant involvement of the pericardium and in 3 of 27 patients with lymph node metastases located mediastinally and subcarinally where only MRT showed a positive involvement of the pericardium or lymph nodes (with possible consequences for the staging of the tumour or lymph nodes). Decisive advantages of MRT compared with CT were seen in the identification of infiltration of the aortic-wall, in the differentiation of the poststenotic syndrome, in the visualisation of the thoracic wall infiltration and functional information on blood flow rate in upper venolus obstruction caused by a carcinoma.

Necrosectomy and postoperative local lavage in necrotizing pancreatitis

Necrosectomy with postoperative continuous local lavage was performed in a prospective study involving 95 patients with necrotizing pancreatitis. In the same period 567 patients with oedematous-interstitial pancreatitis were treated non-operatively with a hospital mortality rate of 0.7 per cent. In patients with necrotizing pancreatitis the median Ranson criteria score was 4.5 points; operation was required at a median of 7 days after the onset of symptoms because of non-response to conservative treatment. In all, 59 per cent of the patients (56 out of 95) developed extended intrapancreatic parenchymal necrosis, 70 per cent had ascites, and 66 per cent had intra- and extrapancreatic necrosis; 42 per cent of the patients had bacterial infection of the necrotic tissue. For lavage a median of 8 l/24 h of fluid were instilled postoperatively for 25 days (median). The lavage fluid showed high levels of immunoreactive trypsin, phospholipase A2, and endotoxin in the early postoperative period. Hospital mortality rate was 8.4 per cent. Necrosectomy and continuous postoperative lavage can achieve high survival rates in patients with necrotizing pancreatitis. Postoperative local lavage allows the continuous non-operative evacuation of biologically active compounds and devitalized tissue, and avoids damage to remaining vital exocrine and endocrine pancreatic tissue.

[Gastrectomy de nécessité]

According to the principle "gastrectomie de nécessité" a total gastrectomy may have to be performed when the distance between the proximal edge of the tumour and the cardia is less than an adequate margin of security. The main reason for advocating this principle is that a large number of patients (ca. 20%) can profit by the advantages of a partial resection above all concerning the nutritional status and the quality of life. Against this principle it is argued that in the presence of a diffuse type carcinoma the risk of local recurrence is considerably higher.

[Magnetic resonance tomography of intrathoracic tumors]

65 patients suspected of having intrathoracic masses were studied using magnetic resonance imaging (MRI) and computed tomography (CT). The intensity difference between mass and adjacent normal tissue or mediastinal fat was greater on MRI than on CT images. MRI was superior to CT in differentiating bronchogenic carcinomatous tumours from postobstructive pneumonia and/or lobar collapse. MRI images most clearly depicted obstructed mediastinal vessels and were also able to indicate intravenous flow reductions. The latter could be demonstrated by an increase of signal intensity within venous structures proximal to the obstruction. In patients with lung cancer no significant differences were found between the two imaging methods for the evaluation of tumour extent or node involvement.

Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis

Local septic complications in acute pancreatitis need to be exactly characterized and defined in order to develop improved concepts for their prevention, early diagnosis, and therapy. While up to now all local septic complications have been termed abscesses, the present study for the first time delineates the morphologic, clinical, and laboratory criteria needed to distinguish between two separate clinical entities: the infected necrosis (IN) and the pancreatic abscess (PA). IN is defined as a diffuse bacterial inflammation of necrotic pancreatic and peripancreatic tissue, but without any significant pus collections. On the other hand, the morphologic substrate of PA is a localized collection of pus surrounded by a more or less distinct capsula. IN becomes clinically evident during the early phase of acute pancreatitis (AP). The patients with IN present both the signs of sepsis and the laboratory findings of AP. Thus in these patients the most fulminant course of AP is observed; 51.8% and 35.7% of them have pulmonary or renal insufficiency, respectively. The mortality of the patients with IN is high and amounts to 32.1%. Pancreatic abscess, on the other hand, does not develop before the fifth week after onset of symptoms and after subsidence of the acute phase of pancreatitis. In these patients laboratory signs of AP-like amylasemia, hypocalcemia, hyperglycemia, and rise of LDH are rarely observed. Corresponding to the lack of pathophysiologic effects of AP per se, pulmonary and renal insufficiencies occur in only 33.3% and 16.7%, respectively, and mortality in these patients is 22.2%. While an abscess may readily be identified by computed tomography, the differentiation between IN and non-IN can be very difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Sepsis indicators in acute pancreatitis

Twenty-one routine clinical and laboratory data in 161 patients with necrotizing pancreatitis (NP) undergoing surgical treatment were analyzed. The necrotic tissue at operation was bacterially infected in 41% of the patients. The goal of the study was to evaluate whether there was any special clinical feature in cases of an infection. The parameters were recorded during 48 h after admission as well as during 48 h before operation, and the frequencies submitted to both a univariate and a multivariate analysis (logistic regression model). In the period after admission, patients with infected necrosis significantly more often had a rectal temperature greater than 38.5 degrees C (p = 0.001). Before operation (i.e., after maximum conservative treatment), four findings were significantly related to an infection: rectal temperature greater than 38.5 degrees C, base excess greater than -4 mmol/L, hematocrit less than 35% (all p = 0.0001), and paO2 less than 60 mm Hg (p = 0.001). The multivariate analysis, which calculates and quantifies the mutual influence of factors, showed a combination of three findings (rectal temperature greater than 38.5 degrees C, base excess greater than -4 mmol/L, and hematocrit less than 35%) to be related to necrosis infection before operation. All three criteria in a patient imply a probability of infection of 83%. It is noteworthy that the sepsis indicators were equally distributed in patients with focal, extended, or subtotal/total infected necrosis, but correlated with the necrosis extent in sterile necrotizing pancreatitis. Moreover, all parameters not related to the pancreatic infection [e.g., hyperglycemia, hypocalcemia, rise of lactic dehydrogenase (LDH), and the white blood cell count] correlated with the three necrosis categories.

[Peptic ulcer: therapeutic principle of vagotomy]

The selective proximal vagotomy (SPV) is the surgical procedure of choice today in patients with duodenal ulcer. The ulcer can be cured in 90-95% of all cases, if the indication for surgery is correct and the operation is performed by a technically experienced surgeon. The rate of complications and postoperative side-effects is extremely low as compared to the risks in patients suffering from an ulcer complication. If the peptic ulcer is located in the prepyloric region or high in the stomach, the SPV cannot be generally recommended; its application in these cases has so far been justified only within the scope of clinical studies.

High sensitivity and specificity of CA 19-9 for pancreatic carcinoma in comparison to chronic pancreatitis. Serological and immunohistochemical findings

The serum carbohydrate antigenic determinant (CA 19-9) was assayed in patients with various diseases (87 patients with pancreatic carcinoma, 747 patients with benign diseases, and 547 patients with extrapancreatic malignant growths) and it proved to be particularly sensitive for adenocarcinoma of the pancreas (80 of 87, 92%) as compared to only 14% in the group of patients with benign diseases. Twenty-seven percent of the patients with chronic pancreatitis and 28% of the patients with acute pancreatitis showed elevated CA 19-9 concentrations of more than the upper normal value of 37 U/ml. In 38% and 32% of our cases with carcinoma of the stomach and colorectal carcinoma, respectively, CA 19-9 was estimated as being above the normal range. The preoperatively raised CA 19-9 concentration in patients with pancreatic carcinoma decreases after curative resection of the carcinoma to values within the normal range. However, in no CA 19-9 estimation following a palliative surgical intervention or in cases of inoperable carcinomas a serum concentration of less than 37 U/ml was recorded. In immunohistochemical specimens we found a difference between CA 19-9 antigen concentrations on the cell surface and secretion in pancreatic carcinoma and chronic pancreatitis.

[Nuclear magnetic resonance tomography of superior vena cava obstruction]

The potential of magnetic resonance tomography (MRT) to demonstrate the mediastinal veins was evaluated retrospectively in 6 patients with superior vena cava obstruction. In each instance, MRT provided detailed information about the extent of venous obstruction and the precise site of the causative oncological pathology. Transaxial images most clearly and unequivocally depicted obstructed superior vena cava. MRT was also able to indicate some secondary effects of superior vena cava obstruction such as slow intravenous flow. The latter could be demonstrated by a significant increase of signal intensity within venous structures proximal to the obstruction. Peripheral venous collaterals in the chest wall were better seen with contrast enhanced computed tomography scans.

The value of CA 19-9 in gastric and colorectal carcinoma

We have conducted a prospective study of 441 patients, to investigate the utility of a new tumor marker CA 19-9 for the diagnosis and monitoring of patients with cancer of the gastrointestinal tract (93 patients with colorectal carcinoma, 57 with carcinoma of the stomach, 10 with esophageal carcinoma, 45 with malignancies outside the gastrointestinal tract, and 236 with benign general surgical disease). Results were compared to those obtained for carcinoembryonic antigen (CEA) in the diagnosis of carcinoma of the stomach and colon/rectum. CEA is more sensitive than CA 19-9 in all stages of carcinoma of the stomach and colon/rectum. During treatments of gastrointestinal carcinomas, CEA and CA 19-9 were determined at the same time in 66 and 165 patients with surgically treated carcinoma of the stomach and colorectal carcinoma, respectively. It was noted that CEA is more sensitive than CA 19-9 in detecting recurrence. However, CA 19-9 is more specific. The best results were obtained when both markers were used together.

[Esophagojejunostomy--how safe is manual suture today?]

Between 1982 and 1986 a total of 137 patients were gastrectomized for cancer of the stomach. The esophago-jejunal anastomosis was always carried out as an end-to-side anastomosis applying the conventional two layer technique. Only in 1 patient (0.7%) an insufficiency of this anastomosis was observed; 9 reoperations (6.6%) were necessary and 3 patients (2.2%) died in the postoperative course. These results confirm that with a precise, standardised conventional suture technique the esophageal anastomosis can be safely performed today.

[Resorption and hormonal reaction in the perioperative phase following enteral administration of glucose]

It was the aim of this study to find out whether a postoperative enteral nutrition with glucose is possible. Therefore, an intraduodenal glucose load (15 g/7.5 min.; 20% solution) was applied in 14 patients with normal weight and no metabolic disorders before and on 4 consecutive days after a medium severe abdominal operation. The results show that the resorption of the enterally applied glucose is reduced only on the first postoperative day. After the peak values have been reached, the decrease of glucose from the blood is delayed up to the second postoperative day, although during the whole testing period the insulin secretion--calculated according to the insulinogenic index - corresponds to the glucose stimulation. Thus, an early postoperative enteral nutrition with glucose seems to be possible, but the reduced absorption over a short period has to be taken into consideration.

Identification of pancreas necrosis in severe acute pancreatitis: imaging procedures versus clinical staging

One hundred and five of 395 patients with acute pancreatitis were surgically treated in our clinic from 1981 to 1984. Ninety three of these patients were examined with contrast enhanced computed tomography and/or ultrasound and were clinically assessed according to Ranson's objective criteria before operation. At operation, 77 patients showed necrotising pancreatitis and 16 showed biliary acute interstitial pancreatitis. Ninety per cent of the cases with extensive and 79% of those with minor necroses of the pancreas had been demonstrated with contrast enhanced computed tomography. Ultrasound failed to be diagnostic in 24% of the patients due to meteorism; the sensitivity of the diagnostic studies for pancreatic necrosis was 73% regardless of the extent of the process. Using the early objective signs, seven patients with acute interstitial pancreatitis were classified as having a severe attack, whereas 30 patients with necrotising pancreatitis were categorised as mild attacks. We conclude that the contrast enhanced computed tomography is an aid in deciding on conservative or surgical treatment in a case of acute pancreatitis. Ultrasound does not appear to be an adequate method for determining pancreatic necrosis. The early objective signs fail to sufficiently identify the necrotising form of acute pancreatitis.

Bacterial contamination of pancreatic necrosis. A prospective clinical study

In a prospective clinical study including 114 patients with acute necrotizing pancreatitis, but excluding patients with a pancreatic abscess, necrotic material obtained at surgery was tested bacteriologically. Intestinal microorganisms were cultured in 39.4% of the cases. The contamination rate was 23.8% in patients operated on during the first 7 days of the attack; it rose to 71.4% in the third week and decreased to 32.5% after the fourth week. Intra- and extrapancreatic necrosis was more widespread and pancreatitis-associated ascites was more frequent in patients with proven contamination. The number of objective signs was 4.5 (median) and postoperative mortality was 37.8% in bacteriologically positive subjects, whereas the number was 3.5 (median) and mortality was 8.7% in bacteriologically negative patients. Morphologic and clinical alterations were more severe, and the mortality rate was significantly elevated, in patients with a short history of disease and bacterial contamination of necrotic tissue. All 5 patients with pancreatic sepsis who were operated on in the first 7 days of the disease, as compared with 2 of 16 patients with sterile necrosis, died. Thus, it is demonstrated that bacterial contamination of pancreatic necrosis occurs early and frequently, causing a significant increase in morbidity and mortality, particularly when it develops in the initial stages of the attack.

CA 19-9 and pancreatic adenocarcinoma

The diagnostic place value of CA 19-9, a tumor-associated antigen, was tested in 611 patients. This group of patients included 273 patients who suffered from a malignant disease (48 patients with pancreatic carcinomas and 225 patients with extrapancreatic malignant growths) and 338 patients with benign diseases (66 patients with chronic pancreatitis, 36 patients with acute pancreatitis, and 236 patients with general surgical diseases). In 93% of the patients with pancreatic carcinoma (media value, 528 U/ml), in 37% and 19% of the patients with carcinoma of the stomach and colorectal carcinomas (median value 8 U/ml), respectively, the CA 19-9 value was estimated as being above the normal limits of 6 to 37 U/ml. A sensitivity of 93% and a specificity of 85%, as well as a total accuracy of 82%, were established in pancreatic carcinoma during preoperative observation. The preoperatively raised CA 19-9 concentration in patients with pancreatic carcinomas dropped after curative resection of the carcinoma to within normal limits. However, a serum concentration of less than 37 U/ml was not recorded in any CA 19-9 estimation after a palliative surgical intervention, or in any case of inoperable carcinomas.

CA 19-9 and pancreatic adenocarcinoma

The diagnostic place value of CA 19-9, a tumor-associated antigen, was tested in 611 patients. This group of patients included 273 patients who suffered from a malignant disease (48 patients with pancreatic carcinomas and 225 patients with extrapancreatic malignant growths) and 338 patients with benign diseases (66 patients with chronic pancreatitis, 36 patients with acute pancreatitis, and 236 patients with general surgical diseases). In 93% of the patients with pancreatic carcinoma (media value, 528 U/ml), in 37% and 19% of the patients with carcinoma of the stomach and colorectal carcinomas (median value 8 U/ml), respectively, the CA 19-9 value was estimated as being above the normal limits of 6 to 37 U/ml. A sensitivity of 93% and a specificity of 85%, as well as a total accuracy of 82%, were established in pancreatic carcinoma during preoperative observation. The preoperatively raised CA 19-9 concentration in patients with pancreatic carcinomas dropped after curative resection of the carcinoma to within normal limits. However, a serum concentration of less than 37 U/ml was not recorded in any CA 19-9 estimation after a palliative surgical intervention, or in any case of inoperable carcinomas.