Treatment of pancreatic fistulas with somatostatin and total parenteral nutrition

Nineteen pancreatic fistulas were treated with somatostatin (ST) and total parenteral nutrition (TPN). Five of the fistulas developed in an uninflamed pancreas, whereas 14 fistulas developed secondary to a necrotizing or chronic pancreatitis. Fistular output varied between 20 and 800 ml/day (median, 160 ml) during TPN before ST treatment; amylase concentration was 10,500-800,000 UI/l. Twelve of 16 (75%) fistulas were contaminated with bacteria. Thirteen of 19 (68%) fistulas closed after a median treatment of 7 (range, 2-14) days. Seven of eight fistulas with open drainage to the bowel healed, whereas only one of six with obstructed drainage closed. All of the uninfected fistulas and half of the infected fistulas closed. The findings suggest that somatostatin treatment speeds up the closure of pancreatic fistulas with open drainage to the bowel but is not beneficial when the intestinal drainage of the fistular region to the bowel is obstructed.

The suction knife in liver surgery

A simple, inexpensive alternative method of blunt dissection for dividing liver parenchyma utilizing a suction knife is presented. The device, made from an ordinary suction tube, has been used successfully in six patients. Details of the device and method are discussed herein.

Comparison of surgical lasers and conventional methods in skin incisions

Steel scalpel, electrocautery, CO2 laser used in a continuous wave mode (CW) and rapid superpulse mode (RSP), and contact Nd: YAG laser were tested on pig skin incisions. Speed of incision and histological changes near the wounds were examined. Light microscopical observations were made on postoperative day 0 using standard Van Gieson stain. Width of the scar on postoperative day 14 was also measured. Steel scalpel produced the least pathological changes in the skin, followed by RSP. Electrocautery did not differ significantly from the CO2 lasers in this respect on postoperative day 0. The damage was larger after contact Nd:YAG laser. The situation was essentially similar on postoperative day 14. The width of the scar was narrowest after steel scalpel and widest after contact Nd:YAG laser (p less than 0.01; Nd:YAG vs. other methods). Electrocautery and the two CO2 lasers produced equal scarring. However, electrocautery was significantly faster than any of the lasers (p less than 0.001).

Magnetic resonance imaging in detecting acute oedematous and haemorrhagic pancreatitis: an experimental study in pigs

The present study was undertaken to evaluate the role of magnetic resonance imaging (MRI) in the diagnosis of pancreatic inflammation. It was focused on the use of ultra-low- and low-field MRI imagers because of the good results achieved with them in detecting intracranial oedema and haemorrhage. In addition, there are 16 ultra-low-field MRI imagers in clinical use in the world. Nineteen piglets were examined by computed tomography (CT) and then by two MRI prototype imagers operating at 0.02 and 0.17 T. The level of the pancreas was selected on CT. Oedematous pancreatitis was induced in 9 animals by intraductal injection of autologous bile and haemorrhagic form in 7 animals by intraductal injection of 15% Na-taurocholate-trypsin with simultaneous intravenous secretin injection. After 6 or 24 h the animals were re-examined by both CT and MRI. The results show that haemorrhagic-necrotizing pancreatitis can well be differentiated from oedematous pancreatitis by CT. On MRI using an ultra-low or low magnetic field the pancreas was difficult to identify and the different forms of pancreatitis could not be differentiated. Thus, at present CT with or without contrast enhancement is superior to ultra-low-field MRI in detecting and estimating the severity of acute pancreatitis. Further progress in the MRI techniques probably improves the results in the future.

Lactate dehydrogenase in laser incisions: a comparative analysis of skin wounds made with steel scalpel, electrocautery, superpulse--continuous wave mode carbon-dioxide lasers, and contact Nd:YAG laser

A histochemical method for demonstrating lactate dehydrogenase activity was used in addition to standard Van Gieson stain to study early alterations near wounds made in pig skin by steel scalpel, electrocautery, two modes of CO2 laser (the rapid super-pulse mode and the continuous wave mode), and contact Nd:YAG laser. The enzyme-free zone near the wounds made using the thermal knives appeared to be twice as wide as the necrotic zone observed with Van Gieson stain. In polarized light, the enzyme-free area showed two zones of equal width with respect to birefringence of collagen fibers. The zone lacking birefringence correlated well with that observed with Van Gieson stain. The birefringent zone represented functionally damaged tissue with more or less normal structures by light microscopy. The damage to adjacent tissue caused with the thermal knives seems to be considerably larger than has usually been reported.

Behavior of plasma phospholipase A2 activity in experimental acute pancreatitis according to diet

The effects of standard, fat-rich, protein-rich, and carbohydrate-rich diets combined with either long-term ethanol ingestion or tap water ingestion on the behavior of plasma phospholipase A2 activity during experimental acute pancreatitis were studied in rats. Phospholipase A2 activity was compared with amylase activity in the plasma. Three hundred eighty-four male Wistar rats were randomized into eight groups receiving different diets with either 15 percent (volume for volume) ethanol or tap water for 12 weeks. Thereafter, all groups were subdivided into control (intact) and pancreatitis subgroups. Pancreatitis was induced by retrograde bile infusion into the pancreatic ducts. Sampling was performed 24 hours after induction in the surviving rats. Ethanol ingestion alone and in combination with the fat-rich diet increased the mortality rate (p less than 0.05), whereas the lowest mortality rate was observed in the carbohydrate-rich diet and water and the carbohydrate-rich diet and ethanol groups. Plasma phospholipase A2 activity increased in most of the groups, but it correlated with the mortality rate in the standard diet group only. Plasma amylase activity increased significantly in all groups, but did not correlate with mortality rate. Plasma phospholipase A2 activity seems to be dependent on diet in experimental acute pancreatitis in rats. Plasma amylase activity may be less affected by the dietary composition, but the lack of a correlation with mortality makes it unreliable as a parameter of severity in experimental acute pancreatitis.

Pharmacokinetics of contrast medium in experimental pancreatography

The pharmacokinetics of a contrast medium in experimental pancreatography of 17 piglets were studied by repeated radiographs of the pancreas and by measuring the concentration of I125-labelled CM in the portal vein, inferior vena cava and in the thoracic duct. Intraduodenal and portal vein injections were performed for comparison. Contrast enhancement of the pancreas after pancreatography was measured by CT. High concentrations of CM were seen in the portal vein 40 seconds after pancreatography, demonstrating direct absorption into the local veins. The concentration of CM in lymph exceeded the systemic concentration 15 minutes after injection, suggesting absorption into lymphatic vessels from the pancreas. CT revealed parenchymal filling of the pancreas even though no acinar filling was seen in normal radiographs. This suggests "invisible" parenchymal filling during normal pancreatography.

Laser pancreatectomy. A comparison between dog and pig

Total pancreatectomy was performed in dogs (n = 5) and pigs (n = 6) using a contact Nd:YAG laser with a wave length of 1060 nm. The fiber was connected to a laser scalpel, and a 1.0-mm-diameter sapphire tip was used. The power was set at 10-12 W with a pulse time of 9.9 s. The animals were followed postoperatively (p.o.) for 1 week, and no mortality, infection, or any other complication were observed. Total pancreatectomy was significantly faster to perform in pigs than in dogs (P less than 0.001). The number of ligatures (P less than 0.05) and the amount of bleeding (P less than 0.05) were significantly less in pigs than in dogs. The present paper describes the anatomy of the pancreas in dogs and pigs, and also the technical procedure of total pancreatectomy in both species is presented. In conclusion, total pancreatectomy is easier to perform in pigs than in dogs. Furthermore, the anatomy of the pancreas in the pig resembles much that in man.

Expression of the human transferrin receptor in subrenal capsule assay in the mouse

The expression of a cell proliferation marker, the human transferrin receptor, was studied in ten human gastrointestinal tumors prior to and after implantation under the renal capsule in the mouse (1-6 days). These data were compared to the increase in tumor size in situ, and to the infiltration of inflammatory cells. All tumors studied expressed the transferrin receptor prior to implantation. Forty of 47 implants expressed the receptor, the strongest expression occurring on day 4, accompanied by a reorganization of tumor tissue to a morphology similar to that before implantation. On days 5 and 6 the expression of the transferrin receptor declined. Implants showed maximal increase in size on days 1 and 2, decreased in size on days 3 and 4, and increased again on days 5 and 6. The increase in the size of the implants on days 5 and 6 was accompanied by considerable infiltration of inflammatory cells, and was probably mostly a result of invading host cells and inflammation. If size alone is used as a criterion for tumor proliferation in this subrenal capsule assay, day 4 seems to be the most appropriate for evaluation. This is supported by a strong expression of a proliferation marker, the human transferrin receptor, during this time.

Ionic and non-ionic contrast media used for contrast-enhanced computed tomography in experimental pancreatitis

Contrast enhancement of the pancreas was studied in pigs using dynamic computed tomography in experimental oedematous and haemorrhagic/necrotizing pancreatitis during the first two minutes after injection of an intravenous bolus of non-ionic contrast medium (iohexol). The prospects of separating the two forms of the disease, known to be possible with ionic contrast media, were tested with a non-ionic contrast medium. In the oedematous form, contrast enhancement after 5 hours of the disease was significantly higher than in the haemorrhagic/necrotizing form. Contrast enhancement after 30 hours of disease tended to vary with the severity of the disease, showing that the course of oedematous pancreatitis is dynamic. Intermediate forms occur and follow-up studies are needed during the disease. A non-ionic contrast medium proved as good for separating the two forms of the disease in the early phase as were ionic contrast media. In severely ill patients, non-ionic contrast media should therefore be used.

Contrast-enhanced computed tomography and microangiography of the pancreas in acute human hemorrhagic/necrotizing pancreatitis

Five patients with severe acute pancreatitis had a low contrast enhancement (CE) of the pancreas in computed tomography (CT) and underwent subtotal pancreatectomy. Microangiography and histologic studies were performed on the resected pancreases, and the findings were related to those of CE. All patients had histologically documented hemorrhagic/necrotizing pancreatitis. The more disturbed the vascular anatomy in microangiography, the more hemorrhages and necroses were found in histology. The microangiographic and histologic findings corresponded closely to the low contrast-enhanced CT of the diseased pancreas in each patient. Thus, in the early phase of severe acute pancreatitis, one can detect by noninvasive means which areas of the gland are necrotic and which edematous by a dynamic study of contrast-enhanced CT of the pancreas.

Experimental pancreatography: a comparison of three contrast media

Twenty-five piglets were subjected to experimental transduodenal pancreatography, using three contrast media (CM), namely sodium meglumine diatrizoate (Urografin), meglumine ioxaglate (Hexabrix), and iohexol (Omnipaque), all diluted to a concentration of 300 mg/ml of iodine. The emptying of CM from pancreatic ducts was studied by repeated roentgenograms, and pancreatic irritation by serum amylase and phospholipase A2 measurements. On the 3rd day after pancreatography the glands were removed for histologic examination of tissue damage. Hyperamylasaemia was seen in 53% of the animals 12 to 15 h after examination, to equal extents in each group. Minimal acinar destruction was seen on histologic examination in all cases. The changes were least when diatrizoate was used. The difference from the changes seen in the ioxaglate group was significant (p less than 0.05). Emptying of CM from the ducts was highly significantly (p less than 0.001) faster in the diatrizoate group than in the other groups. Rapid emptying may be an advantage in clinical endoscopic retrograde pancreaticocholangiography.

Microcirculatory effects of somatostatin in acute pancreatitis

Somatostatin, a 28-amino-acid inhibitory polypeptide has been advocated for the treatment of upper gastrointestinal bleeding and acute pancreatitis. This study examines the effect of somatostatin in acute hemorrhagic pancreatitis in piglets (n = 12), weighing 8-12 kg. Six animals served as controls, and received only fluid resuscitation (0.9%, NaCl, 20 ml/kg/h). Six animals received somatostatin treatment consisting of a 15 micrograms/kg bolus i.v. given simultaneously with the induction of pancreatitis, and treatment continued with an intravenous infusion (15 micrograms/kg/h) for 5 h. Cardiac output, heart rate, blood pressure, arterial pO2, hematocrit and serum amylase were recorded before and each hour during the experiment. Regional blood flow in the gastrointestinal area was measured using the microsphere method. The microspheres labelled with three different isotopes were administered before the experiment and at 2 and 5 h, respectively. There was a significant decrease in the cardiac output (p less than 0.05) and an increase in systemic blood pressure in the somatostatin-treated group (p less than 0.025). Pancreatic blood flow decreased by 43% following somatostatin infusion. The decreases at 2 and 5 h were highly significant (p less than 0.005). Blood flow to the mucosal but not muscular region of the stomach was decreased by somatostatin. This study suggests that somatostatin might be harmful in acute pancreatitis due to its adverse effects on pancreatic blood flow and cardiac output. However, somatostatin may be effective in reducing gastrointestinal bleeding. If the drug is used clinically, careful monitoring of the cardiac output is necessary.

Proximal pancreatectomy: a comparison of electrocautery and contact and noncontact Nd:YAG laser techniques in the dog

Proximal pancreatectomy with duodenal preservation is technically difficult. It has often been performed experimentally in pancreatic transplantation studies. Preservation of the pancreaticoduodenal vessels and duodenum provides an excellent method of testing various operative techniques in pancreatic surgery which may lead to further clinical applications. The present study has compared the conventional noncontact Nd:YAG laser technique with electrocautery and a new contact Nd:YAG laser technique for proximal pancreatectomy. There were five dogs in each group, and the pancreatic duct was left open to drain into the abdominal cavity after pancreatic transection in all of the animals. Resection with the contact laser caused significantly less blood loss (109 +/- 74 ml) than the noncontact laser (228 +/- 81 ml), (p less than 0.05). A greater number of ligatures were used in the noncontact laser group (11 +/- 3 ligatures) as compared with the electrocautery group (2.2 +/- 1.6 ligatures) and the contact laser group (5.2 +/- 2.8 ligatures), (p less than 0.005). Noncontact laser and electrocautery resection techniques resulted in necrotizing pancreatitis and death in two animals. The new contact laser system provides a safe and effective method of performing pancreatic surgery.

A simple isotopic assay method for human serum phospholipase A2 activity

An assay using 2-(1-14C)palmitoyl-labelled dipalmitoyl phosphatidylcholine substrate for the determination of serum phospholipase A2 (PLA2) activity is described and validated. The rapid determination of the enzyme activity is enabled by a simple liquid-liquid partition system to replace the laborious thin-layer chromatography used in earlier studies. The PLA2 activity of human pancreatic juice was used for the optimization of the assay. Interference by serum phospholipids can be avoided by using 10 microliter aliquots of serum in the assay, whereas larger amounts caused a progressive inhibition of the enzyme activity. Virtually no enzyme activity is determined in serum from normal healthy subjects (range from 1.2 to 3.0 IU/l). In acute haemorrhagic pancreatitis the PLA2 activity is markedly elevated (range from 10.7 to 42.0 IU/l). Due to the simple extraction of the reaction products the results can be obtained the same day. Therefore, the assay can conveniently be used for the rapid clinical identification of subjects with acute haemorrhagic pancreatitis.

Techniques of liver resection. Comparison of suction knife, ultrasonic dissector, and contact neodymium-YAG laser

Liver resections were performed in 18 pigs with an inexpensive disposable plastic suction knife, an ultrasonic dissector, or a contact neodymium (Nd)-YAG laser. Technical aspects and intraoperative and postoperative data were compared. Intraoperative blood loss was less with the suction knife (112 +/- 28 mL) than with the ultrasonic dissector (149 +/- 45 mL) or Nd-YAG laser (174 +/- 25 mL). Operating time was similar in all groups. The number of ligatures used in the Nd-YAG laser group (12 +/- 1) was significantly less than in the ultrasonic dissector (27 +/- 2) or suction knife (32 +/- 2) groups. In the ultrasonic dissector group, there was an increase in postoperative white blood cell count and liver enzyme levels compared with the other two groups. Light microscopy revealed dilated bile ducts in the ultrasonic dissector resection group, which may reflect biliary stasis. There were no significant differences in mortality among the three experimental groups. Results indicated that the ultrasonic dissector and the contact laser method were not substantially better than an inexpensive, easily modified plastic suction catheter in performing a major nonanatomic liver resection in piglets.

Analysis of 58 patients surviving more than ten years after operative treatment of gastric cancer

We evaluated 58 patients who were still alive more than ten years after operative treatment of gastric cancer. We reexamined their histologic specimens and compared them with those of matched paired controls of the same sex and age who had died of gastric cancer. Forty-two patients consented to a follow-up study. The age of the patients did not affect survival. For patients with gastric cancer, those with distal cancer or an ulcer simulating cancer had had a better prognosis. Forty percent of the patients had had an early gastric cancer. Only two patients had had lymph node metastases in regional lymph nodes, and macroscopic tumor growth through the serosa had been recorded in only four cases. In 23 cases, a distal resection had proved successful. No significant correlation between intestinal or diffuse types of cancer and prognosis was observed. One recurrence after ten years was found; in one case, there was a new cancer in the gastric remnant. In addition, biopsy specimens from two patients showed grave dysplasia. We suggest that throughout their lives annual follow-up examinations be performed in patients who have undergone radical operations for gastric cancer.

C-reactive protein (CRP) and serum phospholipase A2 in the assessment of the severity of acute pancreatitis

The present study examines the value of C-reactive protein (CRP) determinations in the assessment of the severity of acute pancreatitis and the correlation of CRP with serum phospholipase A2 activity and the clinical status. Fifty three patients with acute pancreatitis were studied; 17 with haemorrhagic pancreatitis and 36 with a mild form of the disease. S-phospholipase A2 activity increased significantly (p less than 0.05) in patients with fatal pancreatitis but not in those with mild disease. Phospholipase A2 concentrations were below 10 nmol FFA/ml min in mild, while they rose to 20-40 nmol FFA/ml min in haemorrhagic pancreatitis. In fatal cases very high (up to 50-60 nmol FFA/ml min) serum phospholipase A2 concentrations were recorded. The increase in CRP was greater in the patients with severe pancreatitis. One day after admission mean CRP was 280 mg/l in patients with haemorrhagic and 45 mg/l in those with the mild pancreatitis (p less than 0.001). High CRP values also correlated with the prognostic signs indicative of severe pancreatitis. CRP and S-phospholipase A2 determinations are valuable in the early assessment of the severity of acute pancreatitis, but the CRP assay is much easier to include in hospital routine.

Peritoneal lavage combined with volume therapy in porcine hemorrhagic pancreatitis. Effects on hemodynamics, microcirculation, and peritoneal morphology

Acute hemorrhagic pancreatitis was induced in 15 piglets, after which 8 of the piglets were treated with saline infusion only and 7 were treated with saline infusion and peritoneal lavage. Hemodynamic variables were measured hourly. Organ and peritoneal blood flow was determined at 0, 1, and 5 h with radioactive microspheres. Peritoneal morphology was studied at 0, 1, 3, and 5 h with light microscopy and scanning electron microscopy. According to the results, changes in cardiac output, mean blood pressure, and peritoneal blood flow and the peritoneal inflammatory reaction were similar in the two groups. However, a significant increase in heart rate and a significant decrease in the blood flow to the pancreas, liver, and spleen were observed in the saline group, in contrast to the lavage group. In addition, blood flow to the adrenal glands was significantly higher in the saline group after 1 h. In conclusion, peritoneal lavage prevented the increase in heart rate and the development of a significant decrease in pancreatic blood flow in experimental hemorrhagic pancreatitis. The significance of these findings remains to be further evaluated.

Effects of electrocautery, CO2 laser, and contact Nd:YAG laser scalpel on the healing of intestinal incision

Leakage after intestinal resection is a serious complication with a high mortality rate. A recent study claims that cutting the intestine with the CO2 laser improves the healing of intestinal anastomoses (Ferulano et al: Eur Surg Res 16:127-130, 1984). The present study was undertaken to analyze the effects of electrocautery, CO2 laser, and contact Nd:YAG laser on the healing of intestinal incisions. Fifteen piglets were used and the cutting and reanastomosing were performed by using all cutting methods in each animal in randomized order. Resection sites were 50 cm, 100 cm, and 150 cm distal to the ligament of Treitz. On the seventh day the bursting pressures were measured for each anastomosis. They were 172 +/- 17 mmHg for normal bowel segment and 133 +/- 12, 135 +/- 40, and 139 +/- 17 mmHg for electrocautery, CO2 laser, and Nd:YAG laser, respectively. There were no mortality, no anastomotic leaks, and no statistically significant differences in the bursting pressures, in histology, or in the healing of anastomotic sites, indicating that electrocautery, CO2 laser, and contact Nd:YAG laser scalpel can safely be used in the surgery of small intestine.

[Results of stereotactic treatment of drug-resistant epilepsy]

After a brief review of results reported so far regarding the stereotactic treatment of seizures, the author describes the results achieved with eight patients on whom stereotactic coagulation was performed in the right or left amygdala-hippocampus complex between 1976 and 1983 on account of drug-resistant partial seizures. Except for one case, in which the indications were purely clinical and it proved impossible to influence the frequency of seizures, seizures either ceased or their frequency was reduced. With a mean duration of 15 years, the period of pharmacoresistance until surgery was indicated was far longer than reported in the literature.

Aprotinin and Na2CaEDTA in experimental hemorrhagic pancreatitis in pigs

We have analyzed the effects of aprotinin and Na2CaEDTA on phospholipase A2 activity and on the outcome of experimental pancreatitis in pigs. Hemorrhagic pancreatitis was induced in 29 piglets by infusing Na-taurocholate and trypsin into the pancreatic duct with simultaneous intravenous injection of secretin. Twelve animals serving as controls had no specific treatment. Nine animals were treated with aprotinin and eight pigs with Na2CaEDTA. Ten of the control animals died within 24 h of the induction of pancreatitis, and two of them lived for a week. In the aprotinin group three piglets died within 24 h and two died during the next day; four animals lived for a week. In the Na2CaEDTA group five animals died within 24 h and one the next day; two animals lived for a week. In all the animals serum phospholipase A2 activity increased significantly (p less than 0.01), there being no differences between the groups. In those animals that lived for a week the phospholipase A2 activities decreased on the 2nd day. This decrease was seen in both treated groups. Aprotinin prolonged the survival time of the animals. This prolongation was statistically significant (p less than 0.05, chi-square test, logrank test). Na2CaEDTA did not improve the prognosis of the animals. Neither of the drugs given influenced the serum phospholipase A2 activities during the first hours of the disease.

The effect of peritoneal exudate on peritoneal morphology in experimental acute pancreatitis. A histologic and scanning electron microscopic study

Changes in peritoneal morphology were examined histologically and by scanning electron microscopy during porcine acute hemorrhagic (n = 8) and edematous (n = 9) pancreatitis and after intraperitoneal installation of hemorrhagic pancreatitis-associated peritoneal exudate in healthy piglets (n = 3). In all experimental groups peritoneal inflammatory changes with mesothelial damage were evident already 1 h after the induction of the disease, and increased with time. Hemorrhagic pancreatitis caused desquamation of mesothelial cells and denudation of the basal membrane. Intraperitoneal installation of hemorrhagic pancreatitis-associated peritoneal exudate in healthy piglets caused similar changes, whereas the changes in edematous pancreatitis were much less extensive. Peritoneal exudate accumulating in the peritoneal cavity during hemorrhagic pancreatitis caused early chemical peritonitis characterized by severe inflammation of the peritoneum with destruction of the mesothelial cell layer, leading to denudation of the underlying connective tissue. The significance of these changes in the pathophysiology of acute fulminant pancreatitis remains to be further studied.

Blood circulation in the urethra during hypovolemia--an experimental study

The changes in urethral blood circulation caused by hypovolemia were studied in male piglets to simulate the hemodynamic changes during extracorporeal perfusion used in open-heart surgery. Changes caused by mild pancreatitis were studied which produced a similar reduction in urethral blood flow measured by microspheres comparable to a 34% hemorrhage of the circulating blood volume. According to this study the urethral mucosa is very sensitive to hemodynamic changes. It may be the case that catheter toxicity is more significant when the urethral blood flow is diminished.

Long-term ethanol ingestion causes an increase of phospholipase A2 activity in acute experimental pancreatitis in rats

Alcohol is recognized as one etiological factor in pancreatitis and according to recent studies, phospholipase A2 (PLA2) may be an important factor in the pathogenesis of this disease. However, the effect of chronic ethanol ingestion on PLA2 activity has not been studied in pancreatitis. To clarify the possible relation of these two factors 48 male Wistar rats received 15% (v/v) ethanol in drinking water for 12 weeks and 48 rats served as controls drinking tap water. Blood samples were collected from the control animals by puncturing the abdominal aorta. Experimental pancreatitis was induced by intraductal retrograde infusion of normal rat bile and blood samples collected 24 hr after the infusion. PLA2 activities in the plasma were measured by using the substrate with a 3H-labeled fatty acid in position 2. PLA2 activities in the control group were 11.2 +/- 1.3 (mean +/- SE) nmole/ml/min and 21.7 +/- 3.5 twenty-four hours later (P less than 0.05). In alcoholic rats the activities were 11.1 +/- 1.4 and 54.0 +/- 10.3, respectively (P less than 0.003). The increase of the activities was greater in alcoholic rats and the difference between the groups statistically significant (P less than 0.025). The mortality rate was 4.2% among the control animals and 29.2% in the alcoholic groups (P less than 0.026). The results of this study suggest that chronic alcohol ingestion makes the pancreas vulnerable to severe pancreatitis with high mortality. This is associated with significantly increased activities of PLA2.

Viriplanin A, a new anthracycline antibiotic of the nogalamycin group. I. Isolation, characterization, degradation reactions and biological properties

Viriplanin A, a new anthracycline antibiotic produced by Ampullariella regularis strain SE 47, was isolated from a raw product that demonstrated activity against Herpes simplex viruses. Based on spectroscopic data, the structure of the aglycone, viriplanol, was determined, and the antibiotic was found to contain the sugar moieties 2-deoxy-L-fucose, 4-O-mesaconoyl-L-diginose and decilonitrose. In solution viriplanin A is very unstable to light. The antibiotic belongs to the nogalamycin group and is related to arugomycin and decilorubicin.

Microangiography of the pancreas in experimental hemorrhagic pancreatitis

In experimental hemorrhagic pancreatitis induced with sodium-taurocholate-trypsin, contrast enhancement of the pancreas in computed tomography (CT) has been shown to be decreased in spite of normal pancreatic blood flow. The contrast enhancement in CT depends on blood flow to the organ, capillary permeability and the amount of extracellular fluid in the organ. For further evaluation of the role of microcirculatory changes in our model of hemorrhagic pancreatitis, microangiography was performed in five normal piglets and in ten piglets with acute hemorrhagic pancreatitis. In this experimental model histological studies showed focal necroses, hemorrhages and leucocyte accumulation. In the affected areas microangiography revealed unfilled capillaries and extravasation of contrast medium. Arteries and arterioles were well filled, as in the normal control animals. These severe disturbances in the capillary circulation of the pancreas may explain the decreased contrast enhancement of the pancreas in CT during acute hemorrhagic pancreatitis.

Effects of dextran 70 versus crystalloids in the microcirculation of porcine hemorrhagic pancreatitis

The cause of hemodynamic changes occurring during acute pancreatitis remains obscure. Using a pig model of acute hemorrhagic pancreatitis and the reference sample method with 113Tin and 46 Scandium labelled microspheres, blood flow to organs was determined before and five hours after the induction of pancreatitis. Blood pressure, pulse rate and cardiac output were measured hourly. There were two treatment groups. The first group received dextran 70 (5.7 milliliters per kilogram per hour) and saline solution (7.5 milliliters per kilogram per hour) in sufficient amounts to maintain cardiac output at the initial (prepancreatic) level. The second group received saline solution (26 milliliters per kilogram per hour) only and during the experiment the cardiac output was allowed to decrease to approximately one-half of the initial level. In the dextran 70 group, blood flow in various organs stayed at the initial level or was slightly increased. However, in the saline solution group there was a marked and significant decrease in the blood flow in all organs except the antral mucosa, gallbladder and adrenal glands. The changes in the pancreatic fraction of the cardiac output during the experiment were similar to those of other organs in respective treatment groups. In conclusion, adequate infusion of dextran maintains cardiac output and organ microcirculation at the initial level during the early phase of acute hemorrhagic pancreatitis. It is suggested that the hemodynamic changes which develop during acute pancreatitis are mainly secondary to the ensuing hypovolemia and not direct consequences of the pancreatic inflammatory process.

Fatal pancreatitis. A study of 64 consecutive cases

An analysis is presented of 64 fatal cases of acute pancreatitis in the decade 1972-1981. In the same period altogether 2842 episodes of acute or relapsing pancreatitis were treated. The male/female ratio in the fatal cases was 49/15, with mean age 46.9/61.4 years. The mortality rate was 22% among patients with acute hemorrhagic pancreatitis and 2.3% among all patients. Of the patients who died, 23% had fewer than 3 Ranson signs, suggesting mild pancreatitis. The etiology of the disease was alcohol in 48% of the fatal cases, biliary disease in 16% and postoperative state in 17%. The study indicated two groups with high mortality rate--young men with a first attack of alcohol-induced pancreatitis and elderly patients with pancreatitis of biliary origin. Systemic complications arose in all patients, the most common being respiratory dysfunction (51%), anuria/uremia (33%) and intra-abdominal complications (31%). The most important causes of death were anuria (27%), respiratory dysfunction (22%) and gastric bleeding (13%).

Hypovolemic shock and contrast-enhanced computed tomography of the pancreas

The effect of profound hemorrhagic hypovolemia on cardiac output and pancreatic blood flow was studied in pigs with the thermodilution method and microsphere technique. Approximately 30-40% of the circulating blood volume was withdrawn slowly during 5 h. Cardiac output and pancreatic blood flow decreased by 35% and 32%, respectively. The animals underwent contrast-enhanced computed tomography (CT) before hypovolemia and at 5 h after its onset. The changes in systemic and local blood flow were related to the contrast enhancement of the pancreas. In spite of profound hypovolemia and a significant decrease in pancreatic blood flow (p less than 0.005), the contrast enhancement remained normal. The results of the present study indicate that pancreatic hypoperfusion caused by hypovolemia does not affect the contrast enhancement of the pancreas in CT.

Total gastrectomy with esophagojejunostomy. Analysis of 100 consecutive patients

One hundred consecutive patients treated for gastric cancer by total gastrectomy from 1977 to 1982 at the second department of surgery of the Helsinki University Central Hospital were analyzed. The mean age of the patients was 61.5 years. Gastroscopy proved to be diagnostically superior to roentgenographic examination, particularly in cases of proximally located cancer. The mean length of postoperative hospital stay was 19.7 days, and the hospital mortality was 8 percent. Respiratory complications accounted for nearly half of the complications, and postoperative intraabdominal complications were recorded in 15 patients. Reoperation was performed on eight patients during the initial hospital stay due to complications. The results suggest that total gastrectomy is a safe procedure with an acceptable mortality rate, and it can be recommended both as a curative and a palliative operation in patients with gastric cancer.

Diagnosis of acute pancreatitis

The diagnosis of acute pancreatitis is still mainly based on the clinical signs and symptoms of the patients. Systemic organ failure, peritonitis and/or shock indicate severe disease, but to obtain optimal results of treatment the diagnosis of individual patients at high risk should be done before the development of systemic manifestations. A number of laboratory tests are valuable in the follow-up of the patients, but immediate onset of intensive therapy cannot be based on these tests. At present, contrast enhanced CT seems to be the most accurate method for the early detection of hemorrhagic/necrotizing forms of acute pancreatitis.

Microangiography of the pancreas in experimental oedemic and haemorrhagic pancreatitis

Microangiography of the pancreas was performed in five normal piglets and in 10 piglets with oedemic and haemorrhagic pancreatitis in order to evaluate the role of microcirculatory changes in experimental pancreatitis. Acute haemorrhagic pancreatitis was induced by intraductal infusion of trypsin-taurocholate and oedematous pancreatitis correspondingly by infusion of autologous diluted bile. Both types of pancreatitis were confirmed by histological examination. Microangiography of the control animals revealed well-filled arteries, arterioles and capillaries, which formed a dense capillary network. In the areas of histologically documented haemorrhagic pancreatitis, unfilled capillary nets were observed as empty areas in the microangiography. Other areas of focal extravasation of the contrast material could be seen. Arteries and arterioles were well filled. In oedematous pancreatitis, the microangiography was unchanged compared with the control.

CONCLUSION

Acute experimental haemorrhagic pancreatitis is associated with severe disturbances in the capillary circulation of the pancreas, whereas in oedematous pancreatitis the microangiography of the pancreas is normal.

Pancreatic secretory trypsin inhibitor-like immunoreactivity in pancreatectomized patients

Pancreatic secretory trypsin inhibitor (PSTI) is a 6000-dalton peptide, that occurs in high concentrations in the pancreas and in pancreatic juice. It is thought to be synthesized by pancreatic acinar cells. We have recently reported the findings of an identical trypsin inhibitor at high concentrations in the urine of patients with gynecological malignancy. Therefore, we have named the inhibitor tumor-associated trypsin inhibitor (TATI). We have now studied patients who have undergone total pancreatoduodenectomy for pancreatic cancer or chronic pancreatitis. By radioimmunoassay (RIA), we found normal levels of this inhibitor in the serum and urine of pancreatectomized patients. The absence of pancreas was confirmed by measuring serum trypsin. By gel filtration and HPLC it was found that PSTI/TATI occurring in pancreatectomized patients was indistinguishable from that found in connection with pancreatitis and ovarian cancer.

Significance of extrapancreatic findings in computed tomography (CT) of acute pancreatitis

Computed tomography (CT) has proven reliable in the early detection of acute haemorrhagic pancreatitis. In the present study the extrapancreatic changes at CT were studied in 60 patients with acute pancreatitis. The CT findings were correlated to the early "prognostic signs" by Ranson and the clinical course of the disease. All the patients with minor extrapancreatic changes recovered without complications. When moderate to severe extrapancreatic changes were seen the incidence of haemorrhagic pancreatitis and the risk of development of pseudocyst or abscess was high. In these patients a dynamic contrast enhanced CT should be done in order to select the patients with haemorrhagic pancreatitis.

Increased serum levels of hyaluronate in liver disease

Recent animal studies show that endothelial cells in liver sinusoids are the main site for removal of sodium hyaluronate from the circulation. Few data with respect to hyaluronate metabolism are available in man. Serum hyaluronate levels were measured in 119 patients with liver disease by a sensitive assay. The hyaluronate level was significantly increased in liver cirrhosis, in comparison with healthy controls and with patients with noncirrhotic liver disease. The results suggest a role for the human liver in elimination of hyaluronate from circulation. Quantification of serum hyaluronate may be a useful test of liver endothelial cell function.

Total pancreatectomy for chronic pancreatitis

Ten instances of total pancreatectomy performed for chronic alcohol induced pancreatitis are reported. There was no hospital mortality, and all of the patients were free of pain. The most difficult problem was labile insulin sensitive diabetes in these patients who were chronic alcoholics. In addition, steatorrhea with weight loss, bleeding marginal ulcers and general weakness diminished working ability. The present data suggest that this procedure should be considered as the last resort in the treatment of severe instances of chronic pancreatitis.

Pancreatic blood flow and contrast enhancement in computed tomography during experimental pancreatitis

The pancreatic blood flow and contrast enhancement in computed tomography (CT) were studied in 10 piglets weighing 17-25 kg with experimental pancreatitis. Each animal served as its own control. CT and blood flow measurements were made both before induction of pancreatitis and 5-6 h after the onset of the disease. Cardiac output was measured by thermodilution, and was kept constant throughout the study by infusion of dextran and saline. Although the pancreatic blood flow remained constant in this experiment, CT showed a significant decrease in contrast enhancement.

A new method for the diagnosis of acute hemorrhagic-necrotizing pancreatitis using contrast-enhanced CT

Twenty-eight consecutive patients with a first attack of alcohol-induced pancreatitis were studied using contrast-enhanced CT. The findings on CT were then related to the course of the disease. The patients with acute hemorrhagic-necrotizing pancreatitis showed significantly lower enhancement values of the pancreatic parenchyma than those with milder forms of the disease. The next 20 patients with severe pancreatitis were scanned using a slightly modified procedure. The enhancement values were calculated and plotted on the graphs for the 2 former groups. Two categories of pancreatic enhancement were found: "low enhancement" and "high enhancement." In all 10 patients with "low-enhancement" values surgery revealed hemorrhagic-necrotizing pancreatitis. In the 10 patients with "high-enhancement" values conservative treatment was continued, and the clinical course was nonfulminant in all of them.

Endotoxaemia and acute pancreatitis: correlation between the severity of the disease and the anti-enterobacterial common antigen antibody titre

Enterobacterial common antigen is a highly immunogenic component of the Gram negative bacterial cell wall that is common to all enteric bacteria. In the present study, the humoral antibody response against enteric bacteria was investigated by measuring antibodies to enterobacterial common antigen in paired serum samples in 38 patients with acute pancreatitis and in 31 healthy subjects. In mild pancreatitis (11 patients), no changes in anti-enterobacterial common antigen titres were observed as compared with healthy controls. Nine of the 10 patients had a significant increase (greater than or equal to 8 times) in anti-enterobacterial common antigen titres during the disease. Similarly, in patients with fulminant (haemorrhagic) pancreatitis who survived, a significant increase in anti-enterobacterial common antigen titres occurred during the course of the disease (in nine of the 11 patients). Paradoxically, only one of the six patients with fulminant pancreatitis with fatal outcome showed a significant increase in his anti-enterobacterial common antigen titre. The results suggest that Gram negative bacterial components escape into the systemic circulation in acute pancreatitis. This may have pathophysiologic significance in this disease.

Elective operations in chronic alcohol induced pancreatitis

The role of surgical treatment in the management of chronic pancreatitis has increased, mainly because of improved diagnostic methods. In the present study, 83 consecutive patients who were operated upon for chronic alcohol induced pancreatitis between 1970 and 1980 are reviewed. The results indicate that the best results with regard to pain relief were achieved with lateral drainage operation in patients with dilated pancreatic ducts. A sufficient pancreatic resection gives satisfactory results in patients with nondilated ducts. Patients with severe pancreatic changes and a long history of alcoholism are best treated by extended pancreatic resections with regard to pain relief; however, most of the patients are still unable to work after the operation. A constant follow-up and active surgical attitude at the early stage of the disease before the circulus vitiosus of pain, drugs, inability to work and disturbances in social life are of paramount importance.

Biochemical markers in non-Hodgkin's lymphoma stages III and IV and prognosis: a multivariate analysis

The prognostic value of different pretreatment laboratory and clinical findings at diagnosis was assessed in a series of 141 patients with generalized non-Hodgkin's lymphoma. Univariate and multivariate survival analysis (Cox's regression model) was performed, using serum analysis of deoxythymidine kinase (S-TK), beta 2-microglobulin, lactic dehydrogenase, alpha 1-acid glycoprotein = orosomucoid (S-alpha 1 AGP), haptoglobin and ferritin. In addition, Hb and the erythrocyte sedimentation rate (ESR) were measured. The clinical variables were age, presence or absence of B-symptoms, histopathology ('low-grade'; 'intermediate grade' and 'high-grade' malignancy) and bone marrow involvement. Of the 8 biochemical markers, all except Hb and the ESR showed a significant relationship to survival. Among the clinical variables, this finding was made for B-symptoms and histopathology. Using a multivariate analysis on all variables, S-TK was found to be the best factor for predicting duration of survival. The only significant additional information was provided by S-alpha 1 AGP. When only the clinical variables were taken into account, it was found that histopathology added significant information to that yielded by B-symptoms in the prediction of the survival time. When the biochemical variables were added to this model, only S-TK was of significant additional prognostic value.

Pancreatic resection versus peritoneal lavation for acute fulminant pancreatitis. A randomized prospective study

Thirty-five patients with acute fulminant (hemorrhagic) pancreatitis, verified at laparotomy, were allocated to either pancreatic resection (18 patients) or peritoneal lavation (17 patients) therapy groups. Pancreatic resection was carried out by removing the distal pancreas well cephalad to the portal vein. For peritoneal lavation, two inlet silicone catheters were inserted at laparotomy around the pancreas and an outlet catheter was inserted in the lower abdomen, and the peritoneal cavity was thereafter lavated (1000 ml/hr) with a standard peritoneal dialysis fluid for 7 to 12 days (or until death if met earlier). In other respects, the postoperative care was similar, including intravenous fluids with total parenteral nutrition until oral intake of food was resumed, prophylactic antibiotics (tobramycin and clindamycin) and stress ulcer prophylaxis (cimetidine and antacids). In the resection group, four of the 18 patients (22.2%) died, while in the lavation group eight of the 17 patients (47.1%) died. The most common cause of death was septic complications with multiple organ failure, but one patient in each group died accidentally of airway complications. There was no difference in the incidence of septic complications (sepsis and/or intra-abdominal abscesses), but the incidence and severity of pulmonary and renal complications were greater in the lavation group. However, these complications accumulated to patients who ultimately died. Also, the need for reoperation was greater in the lavation group (20 reoperations/10 patients versus 12 reoperation/eight patients). Yet, the length of overall hospital stay was equal in the two groups. Six of the 14 survivors in the resection group developed diabetes, whereas none of the nine survivors in the lavation group got this complication. The results suggest that pancreatic resection is superior to peritoneal lavation in the management of acute fulminant (hemorrhagic) pancreatitis, decreasing mortality and affording smoother postoperative course. However, these benefits are gained at the expense of higher incidence of postoperative diabetes.

Distribution of Ia-positive cells in the pig and human pancreas

With monoclonal antibody reacting with both human and porcine Ia antigens, we demonstrate with immunoperoxidase staining that Ia expressing endothelial cells are found in Langerhans' islets as well as in exocrine tissue of the pig and human pancreas. However, neither endocrine cells in Langerhans' islets nor acinar or ductal cells do express the Ia antigen.

The clinical significance of contrast enhanced computed tomography in acute pancreatitis

58 patients with alcohol-induced acute pancreatitis were studied by contrast enhanced computed tomography (CT). The patients were divided into groups both on the basis of the clinical course and the prognostic signs. The contrast enhancement curves were then plotted for these patients. All patients with uncomplicated pancreatitis had increased or normal contrast enhancement, whereas all those with fulminant pancreatitis had decreased contrast enhancement of the pancreas. The patients with three, or more prognostic signs had lower enhancement values than those with fewer prognostic signs, but the prognostic signs did not correlate as well with the clinical course as did the contrast enhancement.