Mindfulness-based stress reduction adapted to pregnant women with psychosocial vulnerabilities-a protocol for a randomized feasibility study in a Danish hospital-based outpatient setting

Background

This protocol is for a feasibility study of a mindfulness-based stress reduction (MBSR) program adapted for pregnant women with psychosocial vulnerabilities. The rationale for the study is the need for a wider array of evidence-based options to address prenatal mental health care needs in pregnant women. MBSR is a promising mental health intervention but has not yet been adapted for pregnant women with the aim of addressing prenatal mental health. The purpose is thus to evaluate the feasibility, acceptability, and clinical outcomes of an adapted MBSR program, prenatal MBSR, compared to usual care to inform a randomized controlled trial.

Methods/design

Pregnant women (n = 60) referred to an outpatient clinic at Copenhagen University Hospital, Amager and Hvidovre, Denmark, will be recruited for the study. The design is a single-center feasibility trial, with prenatal MBSR, as an add-on to usual care. The primary outcome is to assess the feasibility of a full-scale randomized controlled trial. The secondary feasibility outcome includes possible effects of the adapted MBSR program estimated by self-report questionnaires measuring stress, anxiety, depression, well-being, decentering, reflective functioning, mindfulness, and compassion. Participants will be randomized in a 1:1 ratio to prenatal MBSR or usual care.

Discussion

The study is part of the Good Start to Family Life study anchored at Copenhagen University Hospital, Amager and Hvidovre, Denmark. Teaching the skills of mindfulness meditation to a psychosocially vulnerable group of pregnant women could prove a viable and non-pharmacological approach to reduce stress, improve mental health, and provide support in the transition to parenthood. The outcomes of the feasibility study will inform the design of a fully powered randomized controlled trial.

Trial registration

ClinicalTrials.gov, NCT04571190. Registered on September 30, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00860-w.

Benefits of Robotic Camera Assistance in Minimally Invasive Bariatric Procedures: Prospective Clinical Trial Using a Joystick-Guided Camera-Holder

BACKGROUND

While minimally invasive surgery is a growing sector in medicine, camera assistance remains a problem. Especially in bariatric surgery, the assistant holding the camera faces certain challenges. Furthermore, unless the surgeon controls the camera movement themselves, they will be challenged by an unstable image. The aim of this study was to investigate the benefits of a robotic camera assistant (SoloAssist®, AKTORmed™ GmbH, Barbing, Germany) in bariatric surgery.

PATIENTS AND METHODS

Three hundred thirty one consecutive laparoscopic bariatric procedures were performed with the assistance of a camera robot, including Roux-en-Y gastric bypass, laparoscopic gastric banding, sleeve gastrectomy, and gastroplication. Failures and aborts were documented and 6 surgeons were interviewed regarding their experiences using a questionnaire.

RESULTS

In 18 of 331 procedures, robotic assistance was aborted and the procedure was continued manually, mostly because of a need for frequent changes of position in narrow spaces and adverse angles. Two short circuits, 4 joystick faliures and one malfunction of the control unit were reported. All of the surgeons preferred robotic to human assistance, mostly because of a steady image and the capacity for self-control.

DISCUSSION

The SoloAssist® is a reliable system for minimal invasive procedures, especially in bariatric surgery. It provides more comfortable conditions for the surgeon and their assistant by freeing one hand for other purposes. Even in narrow spaces (e.g., between a voluminous stomach and adipose liver), the robot guarantees a steady image. Slight movements of the camera can be precisely controlled, which leads to increased comfort for the surgeon.

Robotic Camera Assistance and Its Benefit in 1033 Traditional Laparoscopic Procedures: Prospective Clinical Trial Using a Joystick-guided Camera Holder

Despite advances in instruments and techniques in laparoscopic surgery, one thing remains uncomfortable: the camera assistance. The aim of this study was to investigate the benefit of a joystick-guided camera holder (SoloAssist®, Aktormed, Barbing, Germany) for laparoscopic surgery and to compare the robotic assistance to human assistance. 1033 consecutive laparoscopic procedures were performed assisted by the SoloAssist®. Failures and aborts were documented and nine surgeons were interviewed by questionnaire regarding their experiences. In 71 of 1033 procedures, robotic assistance was aborted and the procedure was continued manually, mostly because of frequent changes of position, narrow spaces, and adverse angular degrees. One case of short circuit was reported. Emergency stop was necessary in three cases due to uncontrolled movement into the abdominal cavity. Eight of nine surgeons prefer robotic to human assistance, mostly because of a steady image and self-control. The SoloAssist® robot is a reliable system for laparoscopic procedures. Emergency shutdown was necessary in only three cases. Some minor weak spots could have been identified. Most surgeons prefer robotic assistance to human assistance. We feel that the SoloAssist® makes standard laparoscopic surgery more comfortable and further development is desirable, but it cannot fully replace a human assistant.

Low recurrence rate and low chronic pain associated with inguinal hernia repair by laparoscopic placement of Parietex ProGrip™ mesh: clinical outcomes of 220 hernias with mean follow-up at 23 months

INTRODUCTION

The aim of this study was to demonstrate the safety and the efficacy of the self-gripping Parietex ProGrip™ mesh (Sofradim Production, Trévoux, France) used with the laparoscopic approach for inguinal hernia repair. The incidence of chronic pain, post-operative complications, patient satisfaction and hernia recurrence at follow-up after 12 months was evaluated.

METHODS

Data were collected retrospectively from patient files and were analyzed for 169 male and female patients with 220 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal approach using Parietex ProGrip™ meshes performed in the same clinical center in Germany. Pre-, per- and post-operative data were collected, and a follow-up after 12 months was performed prospectively. Complications, pain scored on a 0-10 numeric rating scale (NRS), patient satisfaction and hernia recurrence were assessed.

RESULTS

The only complications were minor and were post-operative: hematoma/seroma (3 cases), secondary hemorrhage through the trocar's site (2 cases), hematuria, emphysema in the inguinal regions (both sides) and swelling above the genital organs (1 case for each). At mean follow-up at 22.8 months, there were only 3 reports of hernia recurrence: 1.4 % of the hernias. Most patients (95.9 %) were satisfied or very satisfied with their hernia repair with only 1.2 % reporting severe pain (NRS score 7-10) and 3.6 % reported mild pain.

CONCLUSION

This study demonstrates that in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietex ProGrip™ self-gripping meshes is rapid, efficient and safe with low pain and low hernia recurrence rate.

Self-gripping Parietene and Parietex Progrip mesh laparoscopic hernia repair: have we found the ideal implant?

INTRODUCTION

The goal of modern laparoscopic hernia repair is to achieve a high standard of patient safety with a low threshold of hernia recurrence and chronic inguinal pain. In the absence of fixating devices and the use of the self-gripping Parietene and Parietex ProGrip mesh (Covidien AG, Zurich, Switzerland) was evaluated in this prospective clinical study. The incidence of chronic pain, postoperative complications, patient satisfaction, and hernia recurrence at follow-up after 12 and 24 months was recorded.

METHODS

Data were collected retrospectively from patient files and were analyzed for 405 male and female patients with 483 primary inguinal hernias. All patients included had undergone surgical repair for inguinal hernia by the laparoscopic transabdominal preperitoneal (TAPP) approach using Parietex ProGrip meshes performed in the same clinical center in Germany. Pre-, peri-, and postoperative data were collected and a follow-up after 12 and 24 months was performed prospectively. Complications, pain scored on a 0 to 10 NRS scale, patient satisfaction, and hernia recurrence were assessed.

RESULTS

The only complications were minor and were postoperative: hematoma/seroma (nine cases), secondary hemorrhage through the trocar's site (eight cases), hematuria, emphysema in the inguinal regions (both sides), and swelling above the genital organs (one case for each). Two patients had to be reoperated due to a hematoma in inguinal canal. At mean follow-up at 22.8 months, there were only eight reports of hernia recurrence: 1.9% of the hernias. Most patients (94.9%) were satisfied or very satisfied with their hernia repair with only 1.2% reporting severe pain (NRS score 7 to 10) and 3.6% reported mild pain.

CONCLUSION

This study demonstrates that, in experienced hands, inguinal hernia repair surgery performed by laparoscopic transabdominal preperitoneal hernioplasty using Parietene and Parietex ProGrip self-gripping meshes is rapid, efficient, and safe with low pain and low hernia recurrence rate. Since no fixating device or glue is necessary for the procedure, additional cost-effectiveness is achieved.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

[Sleeve gastrectomy--technique, safety, success, trends]

Obwohl Über die laparoskopische Sleeve-Gastrektomie (LSG) noch keine ausreichenden Langzeitergebnisse vorliegen, wird diese Operation mitzunehmender Euphorie durchgefÜhrt. Multicenter-Studien sind in der Rekrutierungsphase, Langzeitergebnisse werden erst in 2–3 Jahren erwartet. Die LSG wird allgemein als eine zÜgig durchfÜhrbare und wenig traumatisierende Operation angesehen. Es gelten aber die gleichen GrundsÄtze der laparoskopischen Chirurgie: sorgfÄltige PrÄparationen, Vermeidung von kreuzenden Klammernahtreihen und das frÜhe Erkennen und Beherrschen von Leckagen. Nur so kann ein hoher operativer Standard gewÄhrleistet werden. Wir verwenden einen 32-CharriÈre-Magenbougie; daraus sollte ein circa 80–100 ml großer Schlauchmagen und ein Magenresektat mit mindestens 1000 ml FÜllungsvolumen resultieren. Werden diese Benchmarks angestrebt, kÖnnen Übergewichtsverluste (EWL) von circa 60% nach 1 Jahr erzielt werden. Sleeve Gastrectomy — Technique, Safety, Success, Trends Despite the lack of sufficient data concerning the long-time results, the morbidity, and the mortality of laparoscopic sleeve resection, this operation is performed with growing enthusiasm. However, general principles of laparoscopic surgery need to be observed to ensure good results. This article describes an operative technique and indication for the operation. Attention must be turned on the complete liberation of the dorsal aspect of the stomach, the absence of crossing staple lines, and the competent handling of intraoperative leakages. The use of a 32 Fr bougie results in a residual stomach volume of about 80—100 ml. Due to a good operative technique and a competent follow-up, excess weight loss (EWL) of about 60% can be achieved within the first postoperative year.

Status of bariatric surgery in Germany--results of the nationwide survey on bariatric surgery 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Ottovon-Guericke University of Magdeburg (Germany) since January 1, 2005.

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an internet online data registry. Perioperative characteristics such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes were investigated.

RESULTS

During the study period 3,123 surgical procedures were performed. In 2005 and 2006, gastric banding (GB) was the operation performed most frequently, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean BMI ranged from 48.5 kg/m2 in 2005 to 48.0 kg/m2 in 2007. Follow-up data after 12 months were available for 63.8% of the patients operated in 2005 and 2006. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from GB to sleeve gastrectomy (SG) and malabsorptive procedures. The BMI of German bariatric surgical patients is substantially higher than that of patients from most other countries. There were no differences in overall outcomes during follow-up as compared to published studies.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

[Quality assurance in bariatric surgery in Germany--results of the German multicentre trial 2005 and 2006]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg.

METHODS

The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before.

RESULTS

629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures.

CONCLUSION

A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Ki-67 immunostaining in pancreatic cancer and chronic active pancreatitis: does in vivo FDG uptake correlate with proliferative activity?

PET with 18F-FDG has been shown to be useful in the detection and staging of pancreatic cancer. However, whether FDG uptake is dependent on proliferative activity is still unclear. The aim of this prospective study was to evaluate a probable correlation between FDG uptake and proliferative activity in benign and malignant pancreatic tumors.

METHODS

Our series consisted of 23 patients with pancreatic cancer and 9 patients with chronic active pancreatitis (CAP). FDG PET was performed within 2 wk before surgery, and standardized uptake values (SUVs) were calculated for benign and malignant pancreatic tumors. Patients were selected when focally increased FDG uptake in previously known pancreatic tumors was present. Proliferation fraction was measured in tissue specimens using the anti-Ki-67 antibody MIB-1. A computer-assisted imaging system was used for quantification of nuclear Ki-67 immunostaining. Immunohistochemical findings were correlated to SUVS:

RESULTS

Pancreatic cancer showed both intense nuclear staining of Ki-67 (39% +/- 16%) and high FDG uptake (SUV = 3.6 +/- 1.6). However, no significant correlation was found between in vivo FDG uptake and Ki-67 immunoreactivity (P = 0.65). By contrast, Ki-67 nuclear staining was significantly lower (3.8% +/- 2.7%, P < 0.05) in CAP, whereas FDG uptake was in the same range as for pancreatic cancer (SUV = 3.5 +/- 1.8).

CONCLUSION

FDG uptake did not correlate with proliferative activity in pancreatic cancer. Proliferative activity was tenfold higher in malignant pancreatic tumors than in benign tumors associated with CAP, whereas FDG uptake in vivo did not differ significantly. Thus, a PET tracer indicating cellular proliferation should better differentiate between cancer and inflammatory lesions than do metabolic markers such as FDG.

Neoadjuvant, adjuvant, and palliative treatment of pancreatic cancer

Pancreatic cancer remains a highly malignant disease. Curative treatment is only possible for patients diagnosed at a very early stage. Therefore, the vast majority of pancreatic cancer patients receive palliative treatment. Surgical palliation is offered to patients who are found not to have a resectable tumor. The treatment of obstructive jaundice is managed by stenting of the common bile duct or by a surgical bypass. The best possible surgical procedure should be based on the factors that influence hospital mortality, length of survival, and quality of life. In patients with a life expectancy of longer than 3 months, surgical bypass is recommended, with hepaticojejunostomy the treatment of choice. In the same surgical procedure, the relief of duodenal obstruction with a gastroenteric bypass should be achieved. Chemotherapy, radiotherapy, or a combination of both is employed as a neoadjuvant measure, as an adjuvant treatment, or, in most patients, as palliation. As palliative chemotherapy alone, 5-fluorouracil (5-FU) plus folinic acid is still the treatment of choice; however, newer drugs, such as gemcitabine, seem to have similar or marginally better results. Palliative radiochemotherapy with external-beam radiation plus 5-FU and folinic acid seems to lead to better local control of tumor progression but not to better survival, for which distant metastases are the limiting factor.

Type V collagen regulates the assembly of collagen fibrils in cultures of bovine vascular smooth muscle cells

Vascular smooth muscle cells (SMCs), the major cellular constituent of the medial layer of an artery, synthesize the majority of connective tissue proteins, including fibrillar collagen types I, III, and V/XI. Proper collagen synthesis and deposition, which are important for the integrity of the arterial wall, require the antioxidant vitamin C. Vitamin C serves as cofactor for the enzymes prolyl and lysyl hydroxylase, which are responsible for the proper hydroxylation of collagen. Here, the role of type V collagen in the assembly of collagen fibrils in the extracellular matrix (ECM) of cultured vascular SMCs was investigated. Treatment of SMCs with vitamin C resulted in a dramatic induction in the levels of the cell-layer associated pepsin-resistant type V collagen, whereas only a minor induction in the levels of types I and III collagen was detected. Of note, the deposition of type V collagen was accompanied by the formation of striated collagen fibrils in the ECM. Immunohistochemistry demonstrated that type V collagen, but not type I collagen, became masked as collagen fibrils matured. Furthermore, the relative ratio of type V to type I collagen decreased as the ECM matured as a function of days in culture, and this decrease was accompanied by an increase in the diameter of collagen fibrils. Together these results suggest that the masking of type V collagen is caused by its internalization on continuous deposition of type I collagen on the exterior of the fibril. Furthermore, they suggest that type V collagen acts as framework for the initial assembly of collagen molecules into heterotypic fibrils, regulating the diameter and architecture of these fibrils.

Need for a standard report and future directions in pancreatic resections for cancer

The ability to compare treatment results is essential for the proper evaluation of treatment protocols. Especially in the case of exocrine pancreatic cancer different classifications and documentation systems hinder the comparison between institutions and do not allow multicenter analysis across the world. This might explain the vastly different results of similar therapeutical trials and studies. In the classifications used at present, the features included, as well as terminology and description, vary greatly. First attempts to stage pancreatic malignancies according to UICC criteria were mentioned in the 1987 edition. These rules were predominantly based on the suggestions of the AJCC Cancer of the Pancreas Task Force of 1981 and have since not been changed. In Japan a different staging system has emerged and was first published by the Japanese Pancreatic Society (JPS) in 1986: General Rules for Surgical and Pathological Studies on Cancer of the Pancreas. The major difference between the two classifications concerns the evaluation of local tumor growth and the extent of lymph node involvement. Unfortunately most attempts to 'restage' Western patients postoperatively according to the JPS criteria, or vice versa, in order to compare treatment results have not added to a clearer understanding. Much in contrary, the results were frequently confusing since not comparable data were nevertheless retrospectively compared. Thus, a uniform standard report is needed, leading to prospective data acquisition and biometric analysis of outcome. The report should serve as a standard format for worldwide data acquisition and documentation and thereby become the common language to describe diagnosis, treatment, pathology and outcome of pancreatic cancer patients undergoing surgical therapy. It should enable: (1) inter-institutional data exchange from different staging systems; (2) comparisons between institutions on an international basis; (3) quality management in clinical practice and studies, and (4) reliable insight into tumor biology and differences in growth patterns.

Development of a disease specific quality of life (QoL) questionnaire module to supplement the EORTC core cancer QoL questionnaire, the QLQ-C30 in patients with pancreatic cancer. EORTC Study Group on Quality of Life

There is overwhelming consensus that quality of life assessment is urgently required in pancreatic cancer, yet little research has been conducted. We report on the development of a disease specific questionnaire module to supplement the EORTC core cancer module, the QLQ-C30 in patients with pancreatic cancer, using EORTC quality of life study group guidelines for module development. Relevant QoL issues were generated from literature searches and interviews with health professionals and patients with pancreatic cancer. Issues were constructed into items and provisionally translated. The provisional module was pretested in patients in 8 European centres. The resulting module the QLQ-PAN26 includes 26 items related to disease symptoms, treatment side-effects and emotional issues specific to pancreatic cancer. This should ensure that the module will be sensitive to assess the small but important disease and treatment related QoL changes in pancreatic cancer. The use of the QLQ-C30 and QLQ-PAN26 will provide a comprehensive system of QoL assessment in international trials of pancreatic cancer.

Levels of serum neopterin are increased in pancreatic cancer patients and correlate with the prognosis

Neopterin has been recognized as a valid marker for cellular immune activation. Raised neopterin levels indicate the stimulation of macrophages and indirectly T-cell activation. So far no data is available on serum neopterin in pancreatic cancer patients.

PATIENTS

In this prospective clinical study serum neopterin values were evaluated in 83 patients with adenocarcinoma of the pancreas (PC), 47 patients with chronic pancreatitis (CP), 8 patients with cystadenocarcinoma (CA) of the pancreas and 24 healthy controls (HC).

RESULTS

Serum neopterin was significantly elevated in PC (p < 0. 05) and CA (p < 0.04) as compared to HC. There was no difference found between CP and HC. Pancreatic cancer patients with neopterin levels above 2 pmol/ml had a significantly better survival (p < 0. 05) regardless of stage. In stage III and IV (UICC) this difference was highly significant (p < 0.001). Serum levels of neopterin in resectable patients were also significantly correlated with increased survival and in multivariate analysis proved to be an independent prognostic factor. Neopterin in PC was neither correlated with sex, resectability nor with CA 19/9 and CEA.

CONCLUSIONS

Patients suffering from PC who did show activated cellular immune response reflected in elevated neopterin levels above 2 pmol/ml had a significantly better prognosis regardless of tumor stage. In advanced stages elevated neopterin concentrations were significantly associated with increased survival. Cellular immune response seems to influence survival in these advanced stages to a higher degree as expected. These findings underline the possibility for supportive immunotherapy in this patient group.

Lymph-node dissection in pancreatic cancer -- what are the facts?

BACKGROUND

The surgical therapy of ductal adenocarcinoma of the pancreas is well standardized around the world, with the exception of the extent of the resection of regional lymph nodes and peripancreatic soft tissue. This much-debated issue has become apparent after several Japanese reports that were able to demonstrate better survival after extensive lymph-node clearance. These results, however, could not be achieved using similar techniques in the Western world. The reason for these apparent differences in surgical results result from the application of two different staging systems (UICC and JPS) and the fact that the study designs of the compared trials are not comparable. The most desirable source of information coming from a randomized controlled study is, to date, only available from one trial which was not able to demonstrate a significant survival difference.

CONCLUSION

So far, there is no substantial proof that extensive lymph-node clearance is beneficial for the patient. It has been shown, however, that in specialized centers these procedures do not carry an increased risk of perioperative morbidity and mortality compared with standard resections. In those institutions, the efficacy of extended resections needs to be further evaluated in prospective randomized trials, preferably based on the "International Documentation System for Pancreatic Cancer", which allows data acquisition independent of the staging system applied.

Serum and correspondent tissue measurements of epidermal growth factor (EGF) and epidermal growth factor receptor (EGF-R). Clinical relevance in pancreatic cancer and chronic pancreatitis

CONCLUSION

The results of this study show that routine measurements of epidermal growth factor (EGF) and epidermal growth factor receptor (EGF-R) cannot improve screening for pancreatic cancer despite the frequently present tissue overexpression. Both values fail to reveal this malignancy in a serum test. Patients with chronic pancreatitis exhibit no or very low concentrations of EGF. In cases where preoperative diagnosis is difficult the noninvasive EGF and EGF-R serum measurements may be helpful in discriminating between pancreatic cancer and chronic pancreatitis.

BACKGROUND

EGF and EGF-R are frequently overexpressed in the tissue of patients suffering from ductal pancreatic cancer and to lesser degree in patients with chronic pancreatitis. The aim of this study was to determine the value of serum measurements in these patients to detect malignant pancreatic disease. In cases of pancreatic cancer, the tissue expression of EGF and EGF-R was evaluated by immunohistochemistry.

METHOD

Thirty-five patients with chronic pancreatitis and 31 patients with pancreatic cancer were evaluated; 71 patients admitted for routine surgery (hernia repair, cholecystectomy, goiter surgery) served as controls.

RESULTS

EGF and EGF-R values were not significantly different in pancreatic cancer as compared to controls and did not correlate with other tumor markers (CA 19-9, carcinoembryonic antigen [CEA], tumor polypeptide antigen [TPA]) or with the stage of the disease. Fourteen patients (67%) with pancreatic cancer displayed tissue overexpression for EGF and 11 patients for EGF-R (52%). These patients, however, also failed to exhibit any significant pathological changes in serum concentration. In chronic pancreatitis, EGF and EGF-R were significantly decreased as compared to pancreatic cancer and controls. This was an unexpected finding. There was a positive correlation to clinical exocrine insufficiency.

["No-puncture-laparoscopy" in hernia management in childhood--reliable complement to established therapy concepts]

BACKGROUND

Approximately 50% of children with a clinical unilateral inguinal hernia display a patent processus vaginalis on the contralateral side; half of these children subsequently develop an inguinal hernia. The management of this problem is still controversial. The purpose of this study was to evaluate the usefulness of intraoperative laparoscopy in a non-puncture technique through the opened hernia sack.

METHOD

In 112 children (age 6 months to 7 years) with clinical unilateral hernia laparoscopy (5 mm laparoscope, 30 degrees and 70 degrees). In cases of a wide-open contralateral internal inguinal ring (type III) open surgical exploration was performed.

RESULTS

Nineteen patients (17%) fulfilled the laparoscopic criteria of a type III ring; the diagnose was confirmed during open contralateral exploration. Fourteen of these patients were younger than two years. The median time for laparoscopy was 6 min (3-11 min). No complications associated with the laparoscopy were observed.

CONCLUSIONS

Intraoperative laparoscopy during unilateral hernia repair allows the identification of patients who profit from bilateral open surgery during the same operation with little additional operating time and so far with no resulting complications. Application of this method may avoid a second hospitalization and operation, as well as an unnecessary routine bilateral open exploration. As an additional source of information through excellent visualization of the abdominal cavity, this method proved helpful to examine incarcerated bowel after repositioning.

Small carcinoma of the pancreas. Factors of prognostic relevance

Tumor size seems to be one of the primary prognostic factors that influence outcome in pancreatic cancer patients. This finding is reflected in both the Japanese and the International Union against Cancer (UICC) staging systems, in which T categories have a major influence on stage grouping. To investigate whether small tumor size is a prognostic indicator in patients with pancreatic carcinoma, we evaluated (in a prospective study) patients with a small pancreatic cancer, categorized as T1a (<2 cm) or T1b (<4 cm) tumors according to the UICC (1997).

PATIENTS AND RESULTS

Of 670 treated patients with pan-creatic malignancies, 26 (3.8%) had a small pancreatic tumor (20 T1b; 6 T1a), Twenty-one patients were treated by pylorus-preserving duodenopancreatectomy, 4 patients re-ceived a left pancreatic resection, and 1 patient underwent a total pancreatectomy. All procedures included extensive soft tissue clearance. Local growth pattern was analyzed according to the Japan Pancreas Society (JPS) criteria for pancreatic cancer, i.e., lymph node involvement - N1 (limited to group 1 nodes) was found in 6/26 patients. Serosal infiltration - S1 (single area) was found in 6/26 and S2 (multiple areas) in 6/26; S3 (infiltration to adjacent organs) was found in 1/26. Retroperitoneal infiltration - Rp1 (adjacent to the pancreas) was found in 7/26 and Rp2 (not limited to adjacent tissues, but no other organs involved) was found in 3/26. Venous involvement (Pv2) was found in 1/26. The 5- and 10-year survival rate for the 26 patients was 46%. Interestingly, the T1a tumor patients had a significantly lower 5 year survival rate than the T1b patients (32% vs 58%; P < 0.05). Of prognostic relevance was lymph node metastasis, and retroperitoneal and serosal involvement and these patients had a significantly lower 5-year survival rate than those without such involvement regardless of tumor size (P < 0. 01).

CONCLUSIONS

An overall 5-year survival rate of 46% is exceptionally good. Unfortunately, among pancreatic cancer patients those with a small carcinoma represent a highly selected group, representing less than 5% in our series. Interestingly tumor size is of less prognostic relevance than lymph node, retroperitoneal, and serosal involvement. Radical resection with extensive soft tissue clearance therefore seems essential to achieve such a high survival rate.

The value of intraoperative laparoscopic examination of the contralateral inguinal ring during hernia repair in children

Approximately 40% of children with a clinical unilateral inguinal hernia display a patent processus vaginalis on the contralateral side; half of these children subsequently develop an inguinal hernia. The management of this problem is still controversial. Different strategies to identify patients who profit from an open contralateral exploration have been applied (diagnostic pneumoperitoneum, herniography, ultrasound). The purpose of this study was to evaluate the usefulness of intraoperative laparoscopy in a no-puncture technique through the opened hernia sack. In 75 children (age 6 months to 7 years) with clinical unilateral hernia laparoscopy (5-mm Laparoscope, 30 degrees and 70 degrees ), in cases of wide-open contralateral internal inguinal ring (Type III) an open surgical exploration was performed. Twelve patients (17%) fulfilled the laparoscopic criteria of a Type III ring. The diagnose was confirmed during open contralateral exploration. Seven children (8%) showed a patent but small processus vaginalis with a shallow internal ring. These patients were treated conservatively. In the follow-up period (median 6 months) one subsequent hernia developed. There was no technical failure, and no associated complications were seen. The median time for laparoscopy was 6 minutes. Intraoperative laparoscopy during unilateral hernia repair allows the identification of patients who profit from bilateral open surgery during the same operation with little additional operating time, and so far with no resulting complications. Application of this method may avoid a second hospitalization and operation as well as unnecessary routine bilateral open exploration. As an additional source of information through excellent visualization of the abdominal cavity, this method proved helpful to examine the incarcerated bowel after repositioning.

Carcinoma of the head of the pancreas arising from the uncinate process

BACKGROUND

Carcinoma located in the uncinate process (CUP) of the pancreatic head is considered to be rare. Exact epidemiological data, however, are not available because the series published so far consist of fewer than ten patients. The purpose of this prospective study was to evaluate the clinical appearance of CUP and to compare findings with those of patients with carcinoma in the ventral aspect of the pancreatic head (VPC), which represents the most frequent localization.

RESULTS

Some 39 (8 per cent) of 506 evaluated patients suffered from CUP. Mean age was 63.3 years. The most frequent complaints were upper abdominal pain (n = 32) and weight loss (n = 35). Jaundice was seen in only five patients and was never an early symptom. The level of CA19-9 was raised in 33 patients. The best diagnostic procedure to detect CUP was computed tomography (CT) (sensitivity 93 per cent), whereas endoscopic retrograde cholangiopancreatography was not useful (sensitivity 21 per cent). Vascular involvement was significantly (P < 0.01) more common in CUP (n = 19) than in VPC (48 versus 19 per cent). This finding and the fact that most patients with CUP were diagnosed at a late stage with distant metastasis or severe vascular involvement present (n = 21) are responsible for the significantly lower rate of operation (n = 25) (64 versus 92 per cent, P < 0.05) and the significantly shorter median survival time (5 versus 11 months, P < 0.05).

CONCLUSION

Patients with CUP have a poor prognosis as a result of the lack of early symptoms (jaundice) and early vascular involvement due to the proximity of the uncinate process to the mesenteric root. A raised level of CA19-9, together with weight loss and/or upper abdominal pain, should prompt CT.

Abdominal CT in familial Mediterranean fever: a case report

In order to clarify abnormal findings at abdominal ultrasound (suspicion of late abscess subsequent to appendectomy) in a young male patient with known familial Mediterranean fever (FMF), a helical CT examination of the abdomen was performed. At CT, extensive serositis of the lower abdomen was detected. Findings at CT were verified 2 weeks later at laparoscopy.

International documentation system for pancreatic cancer (IDS). The future in pancreatic cancer evaluation

Different classification systems for pancreatic cancer have evolved in western countries as compared to Japan. While the UICC classification which is focused on tumour size and distant metastasis has achieved widespread acceptance, the more complicated Japanese system seems to be superior in the estimation of local growth. The major drawback of the JPS system, however, is the complex structure and difficult handling. To overcome both the international barriers in classification systems and to achieve a universal prospective data acquisition, a uniform international Documentation System for Exocrine Pancreatic Cancer (IDS for EPC) has been developed by an international group of pancreatologists. The present form of IDS is supported by a software program (based on Microsoft Access) which allows simplified data acquisition and statistical analysis as well as automated stage grouping for the UICC and JPS classifications. From the first contact with the patient, through all diagnostic and therapeutic measures including follow-up, IDS enables a compact and easy-to-use tool for prospective data acquisition and exchange on an international basis.

Inferior pancreaticoduodenal artery aneurysm as a consequence of traumatic acute pancreatitis. A case report and review of the literature

Inferior pancreaticoduodenal artery (PDA) aneurysms are rare: To date, only 88 cases have been reported in the English literature. Although atherosclerosis represents the most common histological finding (60%), the pathogenetic mechanism consists usually of vessel erosion owing to acute or chronic pancreatitis. Most of these lesions are undetectable until symptoms of rupture occur. Rupture occurs typically in association with an episode of pancreatitis (60%) and caries a high mortality rate (50%), making diagnosis and early treatment essential. Angiography and computed tomography (CT) readily confirm the diagnosis. Ligation or resection of the aneurysm represents the definitive and radical therapy, but in an emergency, entails a high mortality rate (50%). Transcatheter embolization is a valid alternative to control bleeding (80%) in order to stabilize the patient; in some cases, it represents a definitive treatment. We present a case of an aneurysm that developed in a patient who had had posttraumatic acute pancreatitis. A surgical procedure with proximal and distal ligation of the aneurysm was performed successfully.

Oxidative stress in acute and chronic pancreatitis

Oxygen radicals mediate an important step in the initiation of acute pancreatitis. These reactive oxygen metabolites are generated at an early stage of the disease. The source of the enhanced production of oxygen radicals, however, still remains unclear. Experimentally, the effectiveness of antioxidant treatment varies from one model to the other, the differences depending on the experimental model and not on the form of pancreatitis that was induced. In most studies, the experimental animals were pretreated before acute pancreatitis was induced. This does not mirror clinical reality because patients are admitted to the hospital after the onset of the disease. It was shown in cerulein-induced pancreatitis, however, that scavenger treatment also mitigated the pancreatic tissue damage after induction of acute pancreatitis. Moreover, antioxidant treatment also attenuated the extrapancreatic complications, thus improving the final outcome of the disease. Initial indirect observations also suggest that in human acute, acute recurrent, and chronic pancreatitis, oxygen free radicals are generated and add to the damage. Concomitantly, these patients suffer from a severe depletion of oxidative stress. Whether or not this disbalance is instrumental in the development and course of disease remains unanswered. Supplementation with antioxidants that are deficient in patients with acute pancreatitis might be a feasible option to the present therapy to avoid extrapancreatic complications. Well-defined, controlled clinical trials involving patients suffering from acute pancreatitis are therefore needed to validate the role of oxygen radicals in this disease.

[Endoscopic and surgical therapy of hemorrhagic duodenal and stomach ulcer]

The aim of this prospective clinical study was to evaluate whether a combination of the endoscopic hemostasis together with fibrin sealing and consecutive conservative therapy could reduce the frequency of recurrent bleedings, thus the number of operations without adversely influencing the prognosis of the disease. 134 patients admitted to the surgical and medical hospital of the University of Ulm between 1/1990 and 1/1992 with bleeding gastroduodenal ulcers took part in this study. All patients were treated endoscopically by hypertonic saline solution plus epinephrine and fibrin sealant. If initial endoscopic hemostasis was not achieved patients were operated within 6 h after admission. Patients with successful initial endoscopic hemostasis were treated conservatively and underwent control endoscopy after 24 and 48 h. In 23 patients the initial endoscopic hemostasis was not successful, they had to be operated immediately. In 111 patients endoscopic hemostasis was achieved, 20% of these patients had acute bleeding ulcers (Forrest Ia, b), 66% showed stigmata of fresh bleedings (Forrest-IIa bleeding). Primary endoscopic hemostasis was achieved in 85.6% of all patients treated, 14.4% of patients (n = 16) developed a recurrent bleeding during the observation period verified by gastroscopy. Half of these patients had an acute bleeding at the first gastroscopy (Forrest-Ia, Forrest-Ib bleeding). Recurrent bleeding became apparent between day 1 and 6 after admission to the hospital. Two patients refused surgical intervention, the other 14 were operated immediately.(ABSTRACT TRUNCATED AT 250 WORDS)

[The role of oxygen radicals in acute pancreatitis. Clinical and experimental results of therapy with free radical scavengers]

Numerous studies support the theory that oxygen free radicals (OR) are involved in the development of tissue damage in all forms of experimental acute pancreatitis. OR are generated in an early phase of the disease before tissue damage is detectable by histology. The pathomechanism that leads to this oxidative stress is not fully understood. The efficacy of scavenger treatment was clearly proven in most models of experimental acute pancreatitis. In first clinical trials applying antioxidant treatment with selenium show favorable results in reducing the lipidperoxidation and improving the antioxidant status. However these preliminary results but must be supported in a larger series of patients to allow proper evaluation of patient outcome.

Lipid peroxidation and glutathione metabolism in chronic pancreatitis

In experimental models of pancreatitis lipid peroxidation products are increased possibly because of an enhanced generation of oxygen radicals. The purpose of this study was to determine whether lipid peroxidation products are increased in pancreatic tissue and serum of patients suffering from chronic or acute pancreatitis. In 20 patients undergoing operative treatment for chronic (n = 11) and acute pancreatitis (n = 9) the levels of malondialdehyde, conjugated dienes, and reduced and oxidized glutathione were determined in resected tissue samples. The excised tissue was examined and evaluated by light microscopy. Shortly before operation the serum concentrations of malondialdehyde, alpha-amylase, and lipase were measured. Pancreatic tissue from eight organ donors who had no abdominal trauma or pancreatic disease served as control. In chronic pancreatitis, conjugated dienes as well as malondialdehyde concentrations in the tissue were significantly elevated. Reduced glutathione was significantly decreased, suggesting glutathione depletion due to oxidative stress. In acute pancreatitis only the tissue and serum malondialdehyde levels were significantly high, whereas conjugated dienes remained within the normal range. Serum malondialdehyde levels correlated significantly with tissue concentrations (r = 0.76; p < 0.05) but not with the clinical course or the enzyme levels. In chronic pancreatitis, the increased tissue levels of lipid peroxidation products and the changes in glutathione metabolism suggest ongoing peroxidation of lipids due to an enhanced generation of oxygen radicals. In hemorrhagic necrotizing pancreatitis, however, oxygen radical-induced lipid peroxidation cannot be proven. Apparently, other pathomechanisms are involved in the development of the severe tissue damage.

Is the elimination of endotoxin and cytokines with continuous lavage an alternative procedure in necrotizing enterocolitis?

Ascites fluid was obtained intraoperatively in 12 consecutively treated neonates (6M, 6F, mean weight 940 g, mean gestational age 27th week, lethality 3/12) suffering from necrotizing enterocolitis (NEC). The concentrations of endotoxin and cytokines (IL-1, IL-6, TNF) were determined. Endotoxin and interleukins were excessively elevated in all patients, TNF only in those who survived. Postoperative treatment included the use of a continuous abdominal lavage system. This therapeutical procedure allows the elimination of endotoxin and cytokines out of the abdominal cavity in order to reduce their adverse biological effect.

Origin of type I collagen localized within oviduct epithelium of quail hyperstimulated by progesterone

Bird oviduct development is controlled by sex steroid hormones. Estrogens (E) induce cell proliferation, formation of tubular glands by epithelial cell evagination and cell differentiation. Progesterone (P) strongly increases secretory processes in E-treated quails, but inhibits cell proliferation and cell evagination. The balance between E and P is very critical for the development and morphogenesis of the oviduct. After six daily injections of low doses of E (10 micrograms day-1) and high doses of P (5 mg day-1) into ovariectomized quails, cell proliferation and secretory process are stimulated but cell evagination is totally inhibited and distribution of striated collagen is perturbed. Using antibodies against type I collagen the stroma, which is mainly composed of fibroblasts, is brightly stained, as are some regions within the epithelium. Electron microscopy shows that bundles of striated collagen fibrils appear in extracellular spaces between the lateral membranes of the epithelial cells or between the basal lamina and the epithelial basal membrane. After in situ hybridization using a 35S riboprobe specific for mRNA of the alpha 2 chain of type I collagen, mRNA was detected only in the fibroblasts of the stroma and not in epithelial cells. Furthermore electron microscope studies of collagen bundles in serial sections clearly show collagen fibrils passing through the basal lamina. It is assumed that the type I collagen between epithelial cells originates from mesenchymal cells. In the oviduct of immature birds or after physiological E + P stimulation, striated collagen is localized only in the stroma and never within the epithelium. These results indicate a modulation of extracellular matrix by sex steroid hormones in the quail oviduct.