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Beger HG. [Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?]. Chirurgie (Heidelb) 2024; 95:461-465. [PMID: 38568302 PMCID: PMC11096214 DOI: 10.1007/s00104-024-02070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 05/16/2024]
Abstract
Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.
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Affiliation(s)
- Hans G Beger
- c/o Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
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Beger HG, Mayer B, Poch B. Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15222-y. [PMID: 38578553 DOI: 10.1245/s10434-024-15222-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/09/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications. MATERIALS AND METHODS Pubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD. RESULTS Concordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15-1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28-0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178-5.34); p = 0.96]. CONCLUSIONS DPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.
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Affiliation(s)
- Hans G Beger
- c/o University Hospital Ulm, University of Ulm, Ulm, Germany.
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Bertram Poch
- Centre for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum Neu-Ulm, Neu-Ulm, Germany
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Beger HG, Mayer B, Poch B. Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity. J Gastrointest Surg 2023; 27:2611-2627. [PMID: 37670106 PMCID: PMC10661729 DOI: 10.1007/s11605-023-05789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/08/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity. METHODS PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval. RESULTS Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients. CONCLUSION DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | - Benjamin Mayer
- Centre for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum Neu-Ulm, Neu-Ulm, Germany
| | - Bertram Poch
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
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Beger HG, Friess H, Uhl W. Whipple Resection for Benign Tumors and Premalignant Neoplasms of the Pancreatic Head: Surgery-Associated Risk for Complications and Late Metabolic Morbidity Matters. Ann Surg Open 2023; 4:e325. [PMID: 37746609 PMCID: PMC10513249 DOI: 10.1097/as9.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/22/2023] [Indexed: 09/26/2023] Open
Abstract
Benign and premalignant neoplasms of the pancreas are increasingly detected and recommended for surgical treatment. For tumors of the pancreatic head, the challenging decision is: multiorgan resection or local tumor extirpation? Compared with pancreaticoduodenectomy, duodenum-preserving pancreatic head resection is associated with significantly fewer surgery-related serious and severe complications and lower in-hospital mortality. The decisive advantage of duodenum-preserving pancreatic head resection is the maintenance of endocrine and exocrine pancreatic and upper gastrointestinal tract functions.
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Affiliation(s)
- Hans G. Beger
- From the Department of Surgery, c/o University of Ulm, Albert-Einstein-Allee, Ulm, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Beger HG, Mayer B, Vasilescu C, Poch B. Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:54-66. [PMID: 33630451 DOI: 10.1097/sla.0000000000004757] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms. SUMMARY OF BACKGROUND DATA Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors. METHODS Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible. RESULTS PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01). CONCLUSION Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Ulm, Germany
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Catalin Vasilescu
- Fundeni Clinical Institute; Department of General Surgery, Bucharest, Romania
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany
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Beger HG, Mayer B, Poch B. Resection of the duodenum causes long-term endocrine and exocrine dysfunction after Whipple procedure for benign tumors - Results of a systematic review and meta-analysis. HPB (Oxford) 2020; 22:809-820. [PMID: 31983660 DOI: 10.1016/j.hpb.2019.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/23/2019] [Accepted: 12/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metabolic dysfunctions after pancreatoduodenectomy (PD) need to be considered when pancreatic head resection is likely to lead to long-term survival. METHODS Medline, Embase and Cochrane Library were searched for studies reporting measured data of metabolic function after PD and duodenum-sparing total pancreatic head resection (DPPHR). Data from 23 cohort studies comprising 1019 patients were eligible; 594 and 910 patients were involved in systematic review and meta-analysis, respectively. RESULTS The cumulative incidence of postoperative new onset of diabetes mellitus (pNODM) after PD for benign tumors was 46 of 321 patients (14%) measured after follow-up of in mean 36 months postoperatively. New onset of postoperative exocrine insufficiency (PEI) was exhibited by 91 of 209 patients (44%) after PD for benign tumors measured in mean 23 months postoperatively. The meta-analysis indicated pNODM after PD for benign tumor in 32 of 208 patients (15%) and in 10 of 178 patients (6%) after DPPHR (p = 0.007; OR 3.01; (95%CI:1.39-6.49)). PEI was exhibited by 80 of 178 patients (45%) after PD and by 6 of 88 patients (7%) after DPPHR (p < 0.001). GI hormones measured in 194 patients revealed postoperatively a significant impairment of integrated responses of gastrin, motilin, insulin, secretin, PP and GIP (p < 0.050-0.001) after PD. Fasting and stimulated levels of GLP-1 and glucagon levels displayed a significant increase (p < 0.020/p < 0.030). Following DPPHR, responses of gastrin, motilin, secretin and CCK displayed no change compared to preoperative levels. CONCLUSIONS After PD, duodenectomy, rather than pancreatic head resection is the main cause for long-term persisting, postoperative new onset of DM and PEI.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany; Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany.
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-Ulm, Germany
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Gavrila D, Lacatus M, Beger HG, Tudor S, Vasilescu C. Limited Parenchyma-Sparing Pancreatic Head Resection for Benign Neuroendocrine Tumors and Cystic Neoplasms—the Use of Duodenum-Preserving Head Resection. Indian J Surg 2020. [DOI: 10.1007/s12262-019-01971-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Beger HG, Mayer B, Poch B. Parenchyma-sparing, local pancreatic head resection for premalignant and low-malignant neoplasms - A systematic review and meta-analysis. Am J Surg 2018; 216:1182-1191. [PMID: 30366596 DOI: 10.1016/j.amjsurg.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/18/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Parenchyma-sparing, local pancreatic head resection, but not pancreaticoduodenectomy (PD) preserves tissue and maintains the pancreatic metabolic functions. METHODS PubMed/Medline, Embase, and Cochrane library collections were systematically searched. Twenty-six cohort studies with 523 cumulative patients, who underwent duodenum-sparing pancreatic head resection (DPPHR), were retrieved. The meta-analysis was based on 14 controlled studies. RESULTS In total, 338 patients suffered cystic neoplasms and 59 PNETs, IPMN-174, MCN-43 and SPN-23 patients. Eighty-one patients (15.5%) histo-pathologically displayed a low-malignant tumor, of which 27 were carcinoma in-situ. Tumor recurrence was observed after a mean follow-up of 47.1 months in 11 patients. In-hospital and late mortality after DPPHR was 0.6% and 1.7%, respectively. The meta-analysis was based on 318 DPPHR compared to 404 PD patients. DPPHR was performed for premalignant neoplasm and PNET in 164 and 46 patients, and PD in 181 and 46 patients, respectively. Events of recurrence displayed no statistically significant difference between the DPPHR and PD groups. CONCLUSION DPPHR is associated with oncologically complete tumor resection for patients suffering premalignant IPMN, MCN, or SPN and for low-risk cancer.
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Affiliation(s)
- Hans G Beger
- C/o University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany; Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany.
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Bertram Poch
- Center for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany
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Abstract
In order to assess the utility of the tumor-associated antigen CA15-3 in the diagnosis of breast cancer, this new tumor marker was measured pre-operatively in 1342 patients. This group comprised 509 patients with malignant disease (134 with breast cancer and 375 with other malignancies not involving the breast) and 833 patients with benign surgical diseases (95 patients with fibroadenoma of the breast, 738 with other benign diseases). The results were compared with those for carcino-embryonic antigen (CEA) in the diagnosis of breast cancer. CA15-3 was above the normal limits of 25 U/ml in 31% of the patients with breast cancer, in 22% of patients with other malignancies, and in 9% of patients with benign diseases. CEA was elevated in 26% of patients with breast cancer (> 3ng/ml). CA15-3 levels were above 50 U/ml in 13% of the breast cancer patients, in 6%) of patients with other malignancies, and in 0.2% of the patients with benign diseases. There was a good correlation between CA 15-3 level and tumor stage in breast cancer. CA 15-3 serum levels were over 50 U/ml in respectively 0%, 2%, 13%, and 73% of the patients with stages I, II, III, and IV. CA 15-3 and CEA were also determined in 671 patients who had received initial curative surgery of breast cancer, and who regularly attended our follow-up clinic. CA15-3 was found to be more sensitive than CEA in detecting recurrences of breast cancer. In the post-care period, carcinoma recurred in 205 patients. Of these 73% had CA15-3 concentrations above 25 U/ml, whereas only 50% had CEA values above 3 ng/ml (p< 0.0001). Although neither CA15-3 nor CEA are sensitive enough for the screening and diagnosis of early breast cancer, CA 15-3 is superior to CEA in the detection of breast cancer metastases.
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Affiliation(s)
- F Safi
- Department of General Surgery, University of Ulm, FRG
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van Brunschot S, Hollemans RA, Bakker OJ, Besselink MG, Baron TH, Beger HG, Boermeester MA, Bollen TL, Bruno MJ, Carter R, French JJ, Coelho D, Dahl B, Dijkgraaf MG, Doctor N, Fagenholz PJ, Farkas G, Castillo CFD, Fockens P, Freeman ML, Gardner TB, Goor HV, Gooszen HG, Hannink G, Lochan R, McKay CJ, Neoptolemos JP, Oláh A, Parks RW, Peev MP, Raraty M, Rau B, Rösch T, Rovers M, Seifert H, Siriwardena AK, Horvath KD, van Santvoort HC. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut 2018; 67:697-706. [PMID: 28774886 DOI: 10.1136/gutjnl-2016-313341] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 06/08/2017] [Accepted: 06/09/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. DESIGN We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). RESULTS Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). CONCLUSION In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Robbert A Hollemans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.,Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Todd H Baron
- Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Hans G Beger
- Department of Surgery, University of Ulm, Ulm, Germany
| | | | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ross Carter
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Jeremy J French
- Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Djalma Coelho
- Department of Surgery, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Björn Dahl
- Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Nilesh Doctor
- Department of Gastrointestinal Surgery, Jaslok Hospital and Research Center, Mumbai, India
| | - Peter J Fagenholz
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gyula Farkas
- Department of Surgery, University of Szeged, Szeged, Hungary
| | | | - Paul Fockens
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Martin L Freeman
- Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy B Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hein G Gooszen
- Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rajiv Lochan
- Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - John P Neoptolemos
- Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Atilla Oláh
- Department of Surgery, Petz-Aladár Teaching Hospital, Györ, Hungary
| | - Rowan W Parks
- Department of Surgery, University of Edinburgh, Edinburgh, UK
| | - Miroslav P Peev
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Raraty
- Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Bettina Rau
- Department of Surgery, University of Rostock, Rostock, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Maroeska Rovers
- Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans Seifert
- Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany
| | | | - Karen D Horvath
- Department of Surgery, University of Washington, Seattle, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht.,Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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Abstract
In order to assess the utility of the tumor-associated antigen CA 72-4 in the diagnosis and monitoring of gastric cancer, this tumor marker was measured preoperatively in 718 patients. This group comprised 282 patients with malignant disease (115 with gastric cancer and 167 with other malig-nancies not involving the stomach) and 476 patients with benign surgical diseases. The results were compared with those for carcinoembryonic antigen (CEA) and the tumor-associated antigen CA 19-9. CA 72-4 was above the normal limit of 2.5 U/ml in 61% of the patients with gastric cancer, in 35% of the patients with other malignancies, and in 7% of the patients with benign diseases. CEA and CA 19-9 were elevated in 37% of the patients with gastric cancer (>3 ng/mlfor CEA and >37 U/ml for CA 19-9). CA 72-4 levels were above 10 U/ml in 26% of the gastric cancer patients, in 15% of patients with other malignancies, and in 0.4% of the patients with benign diseases. There was a good correlation between CA 72-4 level and tumor stage in gastric cancer. CA 72-4 serum levels were over 2.5 U/ml in 31%, 48%, 68% and 88% of patients with stage I, II, III and IV disease, respectively. CA 72-4 was found to be more sensitive than CEA and CA 19-9 in detecting recurrences of gastric cancer. In the postoperative-care period, carcinoma recurred in 29 patients. Of these 93% had CA 72-4 concentrations above 2.5 U/ml, whereas only 59% and 35% had pathological CEA and CA 19-9 serum levels (p<0.002, p<0.0001). Although neither CA 72-4 nor CEA and CA 19-9 are sensitive enough for screening and diagnosis of early gastric cancer, CA 72-4 is superior to CEA and CA 19-9 in the detection of gastric cancer recurrences.
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Affiliation(s)
- F Safi
- Department of General Surgery, University of Ulm, Germany
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Beger HG, Mayer B. [Duodenum-preserving pancreatic head resection in chronic pancreatitis : Limitations of the Heidelberg multicenter ChroPac study]. Chirurg 2018; 89:392-396. [PMID: 29492636 DOI: 10.1007/s00104-018-0615-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The data published in Der Chirurg and The Lancet on the results of the multicenter ChroPac study comparing results of 115 patients in the duodenum-preserving pancreatic head resection (DPPHR) group with 111 patients in the pancreaticoduodenectomy (PD) group, recommend partial PD as the first line procedure for chronic pancreatitis (CP). This is based on the significantly higher frequency of rehospitalization assigned to CP in the DPPHR group and data derived from post hoc meta-analysis about higher frequency of reoperations in the DPPHR group. Based on the presented data of the intention-to-treat analysis it is difficult to support the authors' recommendation of PD as the first line procedure for CP. The critical points are substantial heterogeneity of the different surgical procedures in the DPPHR group (20%) and PD group (13.5%) and a heterogeneity with respect to the number of patients with very advanced CP in the DPPHR group but not in the PD group. The data on the new onset of diabetes and endocrine insufficiency after surgery are not the result of measuring the preoperative and postoperative status of glucose metabolism and degree of exocrine dysfunction but are based on patient records. The advantages and/or disadvantages of the local parenchyma-sparing pancreatic head resection for CP compared to PD results of the published monocentric randomized controlled studies (RCT) more closely verify the clinical evidence than those of the ChroPac trial.
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Affiliation(s)
- H G Beger
- Allgemeine und Viszeralchirurgie, c/o Universität Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - B Mayer
- Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Ulm, Deutschland
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Beger HG. Benign Tumors of the Pancreas-Radical Surgery Versus Parenchyma-Sparing Local Resection-the Challenge Facing Surgeons. J Gastrointest Surg 2018; 22:562-566. [PMID: 29299757 DOI: 10.1007/s11605-017-3644-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/20/2017] [Indexed: 01/31/2023]
Abstract
Pancreaticoduodenectomy and left-sided pancreatectomy are the surgical treatment standards for tumors of the pancreas. Surgeons, who are requested to treat patients with benign tumors, using standard oncological resections, face the challenge of sacrificing pancreatic and extra-pancreatic tissue. Tumor enucleation, pancreatic middle segment resection and local, duodenum-preserving pancreatic head resections are surgical procedures increasingly used as alternative treatment modalities compared to classical pancreatic resections. Use of local resection procedures for cystic neoplasms and neuro-endocrine tumors of the pancreas (panNETs) is associated with an improvement of procedure-related morbidity, when compared to classical Whipple OP (PD) and left-sided pancreatectomy (LP). The procedure-related advantages are a 90-day mortality below 1% and a low level of POPF B+C rates. Most importantly, the long-term benefits of the use of local surgical procedures are the preservation of the endocrine and exocrine pancreatic functions. PD performed for benign tumors on preoperative normo-glycemic patients is followed by the postoperative development of new onset of diabetes mellitus (NODM) in 4 to 24% of patients, measured by fasting blood glucose and/or oral/intravenous glucose tolerance test, according to the criteria of the international consensus guidelines. Persistence of new diabetes mellitus during the long-term follow-up after PD for benign tumors is observed in 14.5% of cases and after surgery for malignant tumors in 15.5%. Pancreatic exocrine insufficiency after PD is found in the long-term follow-up for benign tumors in 25% and for malignant tumors in 49%. Following LP, 14-31% of patients experience postoperatively NODM; many of the patients subsequently change to insulin-dependent diabetes mellitus (IDDM). The decision-making for cystic neoplasms and panNETs of the pancreas should be guided by the low surgical risk and the preservation of pancreatic metabolic functions when undergoing a limited, local, tissue-sparing procedure.
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Affiliation(s)
- Hans G Beger
- Department of General and Visceral Surgery, University of Ulm, c/o Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany. .,Department of Oncology, Endocrinology and Minimal-Invasive Surgery, Donau-Klinikum, 89231, Neu-Ulm, Germany.
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Beger HG, Mayer B. Early postoperative and late metabolic morbidity after pancreatic resections: An old and new challenge for surgeons - A review. Am J Surg 2018; 216:131-134. [PMID: 29478825 DOI: 10.1016/j.amjsurg.2018.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 01/15/2023]
Abstract
The metrics for measuring early postoperative morbidity after resection of pancreatic neoplastic tumors are overall morbidity, severe surgery-related morbidity, frequency of reoperation and reintervention, in-hospital, 30-day and 90-day mortality and length of hospital stay. Thirty-day readmission after discharge is additionally an indispensable criterion to assess quality of surgery. The metrics for surgery-associated long-term results after pancreatic resections are survival times, new onset of diabetes (DM), impaired glucose tolerance, exocrine pancreatic insufficiency, body mass index and GI motility dysfunctions. Following pancreaticoduodenectomy (PD) performed on pancreatic normo-glycemic patients for malignant and benign tumors, 4-30% develop postoperative new onset of diabetes. Long-term persistence of diabetes mellitus is observed after surgery for benign tumors in 14% and in 15.5% of patients after cancer resection. Pancreatic exocrine insufficiency after PD is observed in the early postoperative period in 23-80% of patients. Persistence of exocrine dysfunctions exists in 25% and 49% of patients. Following left-sided pancreatic resection, new onset DM is observed in 14% of cases; an exocrine insufficiency persisting in the long-term outcome is observed in 16-28% of patients.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Germany; Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum, Neu-Ulm, Germany.
| | - Benjamin Mayer
- Department of Epidemiology and Medical Biometry, University of Ulm, Germany
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Abstract
BACKGROUND Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections. METHODS Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively. RESULTS The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2%, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5% of patients; pancreatic fistula in 36.7, 35.2 and 20.1%; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72%; and after DPPHRt/p 0.49%. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001). CONCLUSION EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.
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Affiliation(s)
- H G Beger
- Department of General-and Visceral Surgery, c/o University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany,
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Beger HG, Oettinger W. Bacterial peritonitis in surgery: pathogenesis, symptoms, surgical therapy, peritoneal lavage and progress. Contrib Nephrol 2015; 57:3-9. [PMID: 3677699 DOI: 10.1159/000414257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- H G Beger
- Department of General Surgery, University of Ulm, FRG
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Bittner R, Beger HG, Kraas E, Gögler H. Surgical treatment of carcinoma of the stomach in geriatric patients. Front Gastrointest Res 2015; 5:152-9. [PMID: 499980 DOI: 10.1159/000402323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Beger HG, Nakao A, Mayer B, Poch B. Duodenum-preserving total and partial pancreatic head resection for benign tumors--systematic review and meta-analysis. Pancreatology 2015; 15:167-78. [PMID: 25732271 DOI: 10.1016/j.pan.2015.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and maintenance of pancreatic functions. METHODS Medline/PubMed, Embase and Cochrane Library databases were searched to identify studies applying duodenum-preserving total or partial pancreatic-head resection (DPPHRt/p) and reporting short- and long-term outcomes. Twenty-four studies, including 416 patients who underwent DPPHRt/p, were identified for systematic analysis. The meta-analysis was based on 10 prospective controlled and 4 retrospective controlled cohort studies, comparing 293 DPPHRt/p resections with 372 pancreato-duodenectomies (PD). RESULTS, SYSTEMATIC ANALYSIS Of 416 patients, 75.7% underwent total and 24.3% partial head resection, while 47.1% included segmentectomy of duodenum and CBD. The most common pathology was cystic neoplasm (65.8%) and endocrine tumors (13.4%). The frequencies of severe postoperative complications of 8.8%, pancreatic fistula of 19.2%, re-operation of 1.7% and hospital mortality of 0.48%, indicate a low level of early post-operative complications. META-ANALYSIS DPPHRt/p significantly preserved the level of exocrine (IV = -0.67, 95% CI -0.98 to -0.35, p = 0.0001) and endocrine (IV = 18.20, fixed, 95% CI -0.92 to 25.48, p = 0.0001) pancreatic functions compared to PD when the pre- and postoperative functional status in both groups are analyzed. There were no significant differences between DPPHRt/p and PD in frequency of pancreatic fistula, delayed gastric emptying or hospital mortality. CONCLUSION DPPHRt/p for benign neoplasms and neuro-endocrine tumors of the pancreatic head is associated with a low level of early-postoperative complications and a better conservation of exocrine and endocrine functions.
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Affiliation(s)
- Hans G Beger
- Department of General and Visceral Surgery, University of Ulm, Germany; Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-UIm, Germany.
| | | | - Benjamin Mayer
- Department of Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Bertram Poch
- Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donauklinikum Neu-UIm, Germany
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Beger HG, Poch B, Vasilescu C. Benign cystic neoplasm and endocrine tumours of the pancreas--when and how to operate--an overview. Int J Surg 2014; 12:606-14. [PMID: 24742543 DOI: 10.1016/j.ijsu.2014.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 03/31/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard. OBJECTIVES To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate. RESULTS Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2-3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20% of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11%, pancreatic fistula in 33%. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33% pancreatic fistula and severe post-operative complications of 18% is related to management of proximal pancreatic stump. DPPHRt/s is used in 70% for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10% for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy. CONCLUSION The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
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Affiliation(s)
- H G Beger
- Department of General- and Visceral Surgery, c/o University of Ulm, Ulm, Germany.
| | - B Poch
- Center of Oncologic, Endocrine and Minimal Invasive Surgery, Donouklinikum Neu-Ulm, Germany
| | - C Vasilescu
- Department of General Surgery and Liver Transplantation, Fundei Clinical Institute, Bucharest, Romania
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Beger HG, Schwarz M, Poch B. Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions. J Gastrointest Surg 2012; 16:2160-6. [PMID: 22790582 DOI: 10.1007/s11605-012-1929-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/30/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment. OBJECTIVES The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment. PATIENTS Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed. RESULTS Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ. CONCLUSION Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.
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Abstract
INTRODUCTION In February 1860, B. Langenbeck, Th. Billroth, and G. Gurlt certified in Berlin with the publisher A. Hirschwald the founding of Archiv für Klinische Chirurgie. The journal published extended reports about application of new and case-proven surgical procedures. Separate sections were dedicated to surgical casuistics and small surgical communications and report of surgical institutions from Germany, Austria, and Switzerland as well as annual statistical reports of hospitals. Beginning with the first issue, the Archive was an international journal with the focus on gastrointestinal, trauma, orthopedic, thyroid, and vascular surgery. A section Achievements and Progress in Surgery referred to published results in national and international medical and surgical journals. GERMAN SOCIETY OF SURGERY Surgeons from Germany contributed strongly to the rise of operative treatment concepts in the second half of the nineteenth century by new surgical procedures, many of them published in the Archiv für Klinische Chirurgie. Since 1923, the German Society of Surgery took Archiv für Klinische Chirurgie as the official journal of the society. Beginning 1950, Langenbeck's published in a separate supplement the proceedings of the annual congress of the German Society of Surgery. A second supplement published since 1972 focused exclusively on reporting of research work presented in the section of Surgical Forum for Experimental and Clinical Surgery. AFTER THE WAR After World War II, Langenbeck's Archiv für Chirurgie gained acceptance as the leading scientific surgical journal in Germany. Since 1998, the concept of Langenbeck's Archiv was completely changed to an English journal with the title Langenbeck's Archives of Surgery. In the last 12 years, Langenbeck's has turned to an international German-surgery-based electronic journal. Langenbeck's Archives of Surgery experienced an increasing international reputation; in 2001, only two non-American journals (British Journal of Surgery and Langenbeck's) belonged to the top ten journals in general and GI-tract surgery. The present impact factor (IF) of Langenbeck's Archives of Surgery is 1.829 (5-year IF). The decrease of subscriptions for the journal is compensated by an increase of electronic readers. The electronic supplementary material provided by the Springer Company is used to publish manuscripts in the section How-To-Do Surgery, combined with a video clip about surgical techniques. The focus of Langenbeck's is general, GI-tract, endocrine, and HBP surgery. CONCLUSION Langenbeck's has continuously been published for 150 years and is considered to be the worldwide oldest scientific surgical journal. The English-language-based journal contributes increasingly to an international communication of surgical research and clinical surgeons from Germany.
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Affiliation(s)
- H G Beger
- Universitätsklinik Ulm, Steinhövelstrasse 9, Ulm, Germany.
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Abstract
INTRODUCTION After the routine use of ether narcosis and surgical antisepsis, the evolution of surgery experienced fascinating and genuinely surgical technique-related advancements. Surgeons from Germany contributed strongly to the upturn of operative treatment in the second half of the nineteenth century. DISCUSSION B. von Langenbeck inaugurated in 1852 an osteosynthese device in a patient with pseudoarthrosis. He is credited to be the very first in introducing the principle of fixateur externe. Th. Billroth performed in 1873 the first extirpation of the larynx in a patient with a malignant tumor. Postoperatively, the patient was cared with an artificial larynx. The first successful resection of the distal stomach inaugurated by Th. Billroth in 1881 was later called the Billroth II procedure. Rydygier from Kulm and Billroth from Wien are the first who successfully performed resection of the lower part of the stomach with anastomosis to the duodenum (Billroth I type of resection). In 1883, Th. Kocher from Bern reported 101 cases of thyroidectomy, the largest single-surgeon experience. L. Rehn from Frankfurt did in 1887 the first successful suturing of a beating heart to repair a large stab wound. A. Braun, Königsberg presented in 1892 his techniques of side-to-side anastomosis of the intestine to avoid a circular intestinal anastomosis. F. Sauerbruch from Breslau published in 1904 his thoracotomy chamber with space for two surgeons opening routine access to intrathoracic tissues protecting pulmonary ventilation during surgery. W. Kausch from Berlin reported in 1912 about three successful pancreatic head resections for peripapillary cancer. The first successful pancreatic head resection was performed in 1909 in a patient with a cancer of the papilla. The patient survived for a long term.
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Affiliation(s)
- H G Beger
- Universitätsklinik Ulm, Steinhövelstrasse 9, Ulm, Germany.
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Siech M, Zhou Z, Zhou S, Bair B, Alt A, Hamm S, Gross H, Mayer J, Beger HG, Tian X, Kornmann M, Bachem MG. Stimulation of stellate cells by injured acinar cells: a model of acute pancreatitis induced by alcohol and fat (VLDL). Am J Physiol Gastrointest Liver Physiol 2009; 297:G1163-71. [PMID: 19779015 DOI: 10.1152/ajpgi.90468.2008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mechanisms leading to acute pancreatitis after a fat-enriched meal combined with excess alcohol are incompletely understood. We have studied the effects of alcohol and fat (VLDL) on pancreatic acinar cell (PAC) function, oxidative stress, and repair mechanisms by pancreatic stellate cells (PSC) leading to fibrogenesis. To do so, PAC (rat) were isolated and cultured up to 24 h. Ethanol and/or VLDL were added to PAC. We measured PAC function (amylase, lipase), injury (lactic dehydrogenase), apoptosis (TUNEL, Apo2.7, annexin V binding), oxidative stress, and lipid peroxidation (conjugated dienes, malondialdehyde, chemoluminescence); we also measured PSC proliferation (bromodeoxyuridine incorporation), matrix synthesis (immunofluorescence of collagens and fibronectin, fibronectin immunoassay), and fatty acids in PAC supernatants (gas chromatography). Within 6 h, cultured PAC degraded and hydrolyzed VLDL completely. VLDL alone (50 microg/ml) and in combination with alcohol (0.2, 0.5, and 1% vol/vol) induced PAC injury (LDL, amylase, and lipase release) within 2 h through generation of oxidative stress. Depending on the dose of VLDL and alcohol, apoptosis and/or necrosis were induced. Antioxidants (Trolox, Probucol) reduced the cytotoxic effect of alcohol and VLDL. Supernatants of alcohol/VLDL-treated PAC stimulated stellate cell proliferation and extracellular matrix synthesis. We concluded that, in the presence of lipoproteins, alcohol induces acinar cell injury. Our results provide a biochemical pathway for the clinical observation that a fat-enriched meal combined with excess alcohol consumption can induce acinar cell injury (acute pancreatitis) followed by repair mechanisms (proliferation and increased matrix synthesis in PSC).
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Affiliation(s)
- Marco Siech
- Dept. of General and Vascular Surgery, Ostalb-Klinikum Aalen, Germany.
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Rau B, Steinbach G, Baumgart K, Gansauge F, Grünert A, Beger HG. The clinical value of procalcitonin in the prediction of infected necrosis in acute pancreatitis. Intensive Care Med 2009; 26 Suppl 2:S159-64. [PMID: 18470712 DOI: 10.1007/bf02900730] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Infection of pancreatic necrosis (IN) has a major impact on management and outcome in acute pancreatitis (AP). Currently, guided fine-needle aspiration (FNA) is the only means for an accurate diagnosis of IN. Procalcitonin (PCT), a 116 amino acid pro-peptide of calcitonin has been found in high concentrations in patients with sepsis. In the present study we analyzed the clinical value of serum PCT for predicting IN in AP and compared the results to guided FNA. DESIGN Clinical study. SETTING A collaborative study between the Departments of General Surgery and Clinical Chemistry/ Pathobiochemistry of the University of Ulm, Germany. PATIENTS 61 patients with AP entered this study and were stratified into three groups according to morphological and bacteriological data: I. 22 patients with edematous pancreatitis (AIP), II. 18 patients with sterile necrosis (SN), III. 21 patients with IN. MEASUREMENTS AND RESULTS During an observation period of 14 days PCT was measured by immunoluminometry, CRP was determined by lasernephelometry on a routine base. In patients with IN overall PCT concentrations were significantly higher than in those with SN, whereas CRP levels did not differ in both groups. In contrast, only low concentrations of both parameters were found in patients with AIP. By ROC analysis the best PCT cut-off level for predicting IN or persisting pancreatic sepsis was obtained at > or =1.8 ng/ml. If this cut-off was reached on at least two consecutive days, IN could be predicted with a sensitivity of 95%, a specificity, of 88%, and an accuracy of 90%. Guided FNA achieved a sensitivity, specificity, and accuracy of 91%. 79%, and 84% in differentiating IN from SN, respectively. After surgical treatment of IN median PCT values continued to be significantly higher in patients with persisting pancreatic sepsis (n=12) compared to those with an uneventful postoperative course (n=7). Our results demonstrate that monitoring of serum PCT could serve as a noninvasive and accurate method to predict IN in AP as well as to select patients with persisting septic complications after surgical debridement.
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Affiliation(s)
- B Rau
- Department of General Surgery, University of Ulm, D-89075 Ulm, Germany
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Beger HG, Rau BM, Gansauge F, Poch B. Duodenum-preserving subtotal and total pancreatic head resections for inflammatory and cystic neoplastic lesions of the pancreas. J Gastrointest Surg 2008; 12:1127-32. [PMID: 18299945 DOI: 10.1007/s11605-008-0472-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 01/07/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION For treatment of inflammatory and benign neoplastic lesions of the pancreatic head, a subtotal or total pancreatic head resection is a limited surgical procedure with the impact of replacing the application of a Whipple procedure. The objective of this work is to describe the technical modifications of subtotal and total pancreatic head resection for inflammatory and neoplastic lesions of the pancreas. The advantages of this limited surgical procedure are the preservation of the stomach, the duodenum and the extrahepatic biliary ducts for treatment of benign lesions of the pancreatic head, papilla, and intrapancreatic segment of the common bile duct. For chronic pancreatitis with an inflammatory mass complicated by compression of the common bile duct or causing multiple pancreatic main duct stenoses and dilatations, a subtotal pancreatic head resection results in a long-lasting pain control. Performing, in addition, a biliary anastomosis or a Partington Rochelle type of pancreatic main duct drainage, respectively, is a logic and simple extension of the procedure. The rationale for the application of duodenum-preserving total pancreatic head resection for cystic neoplastic lesions are complete exstirpation of the tumor and, as a consequence, interruption of carcinogenesis of the neoplasia preventing development of pancreatic cancer. Duodenum-preserving total head resection necessitates additional biliary and duodenal anastomoses. For mono-centric IPMN, MCN, and SCA tumors, located in the pancreatic head, total duodenum-preserving pancreatic head resection can be performed without hospital mortality and resurgery for recurrency. Based on controlled clinical trials, duodenum-preserving pancreatic head resection is superior to the Whipple-type resection with regard to lower postoperative morbidity, almost no delay of gastric emptying, preservation of the endocrine function, lower frequency of rehospitalization, early professional rehabilitation, and establishment of a predisease level of quality of life. CONCLUSION The limited surgical procedures of subtotal or total pancreatic head resection are simple, safe, ensures free tumour margins and replace in the authors institution the application of a Whipple-type head resection.
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Affiliation(s)
- H G Beger
- Department of General and Visceral Surgery, University of Ulm (-9/2001), Ulm, Germany.
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Beger HG, Gansauge F, Siech M, Schwarz M, Poch B. Duodenum-preserving total pancreatic head resection for cystic neoplastic lesions in the head of the pancreas. ACTA ACUST UNITED AC 2008; 15:149-56. [PMID: 18392707 DOI: 10.1007/s00534-007-1227-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Accepted: 02/28/2007] [Indexed: 02/04/2023]
Affiliation(s)
- Hans G Beger
- c/o Universitätsklinikum Ulm, Steinhövelstrasse 9, D-89075 Ulm, Germany
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Beger HG, Rau BM, Gansauge F, Schwarz M, Siech M, Poch B. Duodenum-preserving total pancreatic head resection for cystic neoplasm: a limited but cancer-preventive procedure. Langenbecks Arch Surg 2008; 393:589-98. [PMID: 18379818 DOI: 10.1007/s00423-008-0323-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 02/21/2008] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cystic neoplastic lesions of the pancreas are found in up to 10% of all pancreatic lesions. A malignant transformation of cystic neoplasia is observed in intraductal papillary mucinous tumor (IPMN) lesions in 60% and in mucinous cystic tumor (MCN) lesions in up to 30%. For cystic neoplasia located monocentrically in the pancreatic head and that do not have an association with an invasive pancreatic cancer, the duodenum-preserving total head resection has been used in recent time as a limited surgical procedure. PATIENTS An indication to duodenum-preserving total pancreatic head resection is considered for patients who do not have clinical signs of an advanced cancer in the lesion and who have main-duct IPMN and monocentric MCN lesions. In 104 patients with cystic neoplastic lesions in the Ulm series, 32% finally had a carcinoma in situ or an advanced pancreatic cancer. The application of a duodenum-preserving total pancreatic head resection in patients with asymptomatic cystic lesion is based on the size of the tumor and the tumor relation to the pancreatic ducts. For patients who have preoperatively clinical signs of malignancy, a Kausch-Whipple type of oncologic resection is recommended. RESULTS Duodenum-preserving total pancreatic head resection is used in several modifications. The surgical procedure is a limited pancreatic head resection which necessitates segmental resection of the peripapillary duodenum. Hospital mortality is very low; in most published series it is 0%. The long-term outcome is determined by completeness of resection for both -- benign and malignant -- entities. Careful evaluation of the frozen section results has a pivotal role for intraoperative decision making. CONCLUSION A duodenum-preserving total pancreatic head resection is a limited surgical procedure for patients who suffer a local monocentric, cystic neoplastic lesion in the pancreatic head. Absence of an advanced pancreatic cancer and completeness of extirpation of the benign tumor determine the long-term outcome. In regards to the location of the lesion in the pancreatic head, several modifications have been applied with low hospital morbidity and mortality below 1%.
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Beger HG, Rau B, Gansauge F, Leder G, Schwarz M, Poch B. Pancreatic cancer--low survival rates. Dtsch Arztebl Int 2008; 105:255-62. [PMID: 19629206 PMCID: PMC2696777 DOI: 10.3238/arztebl.2008.0255] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 01/10/2008] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cancers of the pancreas are identified in 11 800 to 13 500 patients each year in Germany. Epidemiological studies prove smoking and chronic alcohol consumption as causes of about 30% of pancreatic cancers. METHODS Selective literature review. RESULTS Only patients within TNM stage I and II have after oncologic tumor extirpation a chance for long term survival. Controlled prospective clinical trials demonstrated adjuvant chemotherapy yielding an additional significant survival benefit. The 3- and 5-year-survival after R0-resection and adjuvant chemotherapy are about 30% and below 15% respectively. Using the criteria of observed 5-year-survival less than 2% of all pancreatic cancer patients are alive. After R0-resection the median survival time is between 17 and 28 months, after R1/2-resection between 8 and 22 months. DISCUSSION Pancreatic cancer is even today for more than 95% of the patients incurable. Strategies to prevent pancreatic cancer are intended to stop smoking and chronic alcohol consumption and early surgical extirpation of cystic neoplastic lesions. For patients with established pancreatic cancer risk a follow-up protocol is discussed.
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Affiliation(s)
- Hans G Beger
- Abteilung für Allgemein- und Viszeralchirurgie, Klinikum der Universität Ulm, Steinhövelstrasse 9, Ulm, Germany.
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Buttenschoen K, Kornmann M, Berger D, Leder G, Beger HG, Vasilescu C. Endotoxemia and endotoxin tolerance in patients with ARDS. Langenbecks Arch Surg 2008; 393:473-8. [PMID: 18320210 DOI: 10.1007/s00423-008-0317-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 02/12/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND The significance of endotoxemia in man is controversial, induces cytokine release and stimulates the immune system. Exaggerated cytokine release of mononuclear cells was observed in acute lung injury/acute respiratory distress syndrome (ALI/ARDS). However, repetitive administration of endotoxin can cause tolerance. OBJECTIVE To investigate endotoxemia, plasma TNFalpha, IL-1beta, IL-6, the liberation capacity of those cytokines from mononuclear cells after LPS challenge (Delta values), and plasma antibodies to endotoxins and alpha-hemolysin of Staphylococcus aureus in ALI/ARDS. DESIGN A prospective clinical study was conducted. SETTING The study was carried out at the University Hospital Ulm, Ulm, Germany. SUBJECTS The respondents were 23 patients with ALI/ARDS. INTERVENTIONS ALI/ARDS was defined according to the American-European Consensus Conference on ARDS. Blood was collected periodically. Parameters were measured by LAL or ELISA. RESULTS ARDS (P(a)O(2)/F(i)O(2) < 200) revealed higher endotoxemia (0.22-0.46 [0.06-1.15] EU/mL vs 0.05-0.14 [0.02-0.63] EU/mL) than ALI (P(a)O(2)/F(i)O(2) > 200) but lower DeltaIL-6 (124-209 [10-1214] pg/mL vs 298-746 [5-1797] pg/mL), DeltaTNFalpha (50-100 [6-660] pg/mL vs 143-243 [12-2795] pg/mL), and DeltaIL-1 (2-3 [0-26] pg/mL vs 2-14 [0-99] pg/mL). Endotoxemia correlated negative with P(a)O(2)/F(i)O(2) (r, -0.44 to -0.50). All patients presented antibodies to lipopolysaccharides and alpha-hemolysin, but the level did not correlate with P(a)O(2)/F(i)O(2). CONCLUSIONS ALI/ARDS is associated with endotoxemia. The more severe the disease, the more intense is endotoxemia but the lower is the capacity of mononuclear cells to release cytokines (tolerance). Antibodies against Gram-positive and Gram-negative bacteria are detectable in the plasma but without relation to P(a)O(2)/F(i)O(2).
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Abstract
Chronic pancreatitis (CP), a benign, inflammatory process of the pancreas, can cause severe pain, diabetes mellitus, steatorrhoea, and weight loss and often leads to a significant reduction in the quality of life. In the past decade our knowledge of the pathophysiology of CP has increased together with the number and quality of treatment options available for this disease. In addition to pharmacological and endoscopic treatment modalities, surgical drainage and resection procedures have become increasingly important since they have the potential to provide superior long-term results in patients with CP. The classical and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by organ-sparing procedures like the duodenum preserving pancreatic head resection and its variants. The latter allow better preservation of the exocrine and endocrine pancreatic function, and provide adequate pain relieve and improvement in the quality of life of CP patients.
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Affiliation(s)
- Andre L Mihaljevic
- Department of General Surgery, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
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Abstract
Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (>50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis-Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.
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Abstract
Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis-Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.
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Beger HG, Gansauge F, Schwarz M, Poch B. Pancreatic head resection: the risk for local and systemic complications in 1315 patients—a monoinstitutional experience. Am J Surg 2007. [DOI: 10.1016/j.amjsurg.2007.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
PURPOSE OF REVIEW New understanding of the dynamic of acute pancreatitis, the clinical impact of local pathology in chronic pancreatitis and cystic neoplastic lesions bearing high potential for malignant transformation has changed the management of pancreatic diseases. RECENT FINDINGS In acute pancreatitis, risk factors independently determining outcome in severe acute pancreatitis are early and persistent multiorgan failure, infected necrosis and extended sterile necrosis. The management of severe acute pancreatitis is based on early intensive-care treatment and late surgical debridement. In chronic pancreatitis, recent data from randomized controlled clinical trials have demonstrated duodenum-preserving pancreatic head resection with an inflammatory mass of the head as superior to pylorus-preserving Whipple resection. Cystic neoplasms are local lesions of the pancreas with high malignant potential. Local organ-preserving resection techniques have been applied with low morbidity and mortality, replacing a Whipple-type resection. Resection of pancreatic cancer is ineffective to cure patients. After an R0-resection, a significant survival benefit has been achieved when adjuvant chemotherapy has additionally been applied. SUMMARY New knowledge about the nature of inflammatory diseases, cystic neoplastic lesions and malignant pancreatic tumours has changed the indication for surgical treatment and the application of organ-preserving surgical techniques.
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Affiliation(s)
- Hans G Beger
- Department of General Surgery, University of Ulm, Department of Visceral Surgery, Neu-Ulm, Germany.
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Rau BM, Kemppainen EA, Gumbs AA, Büchler MW, Wegscheider K, Bassi C, Puolakkainen PA, Beger HG. Early assessment of pancreatic infections and overall prognosis in severe acute pancreatitis by procalcitonin (PCT): a prospective international multicenter study. Ann Surg 2007; 245:745-54. [PMID: 17457167 PMCID: PMC1877072 DOI: 10.1097/01.sla.0000252443.22360.46] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic infections and sepsis are major complications in severe acute pancreatitis (AP) with significant impact on management and outcome. We investigated the value of Procalcitonin (PCT) for identifying patients at risk to develop pancreatic infections in severe AP. METHODS A total of 104 patients with predicted severe AP were enrolled in five European academic surgical centers within 96 hours of symptom onset. PCT was measured prospectively by a semi-automated immunoassay in each center, C-reactive protein (CRP) was routinely assessed. Both parameters were monitored over a maximum of 21 consecutive days and in weekly intervals thereafter. RESULTS In contrast to CRP, PCT concentrations were significantly elevated in patients with pancreatic infections and associated multiorgan dysfunction syndrome (MODS) who all required surgery (n = 10) and in nonsurvivors (n = 8) early after onset of symptoms. PCT levels revealed only a moderate increase in patients with pancreatic infections in the absence of MODS (n = 7), all of whom were managed nonoperatively without mortality. A PCT value of > or =3.5 ng/mL on 2 consecutive days was superior to CRP > or =430 mg/L for the assessment of infected necrosis with MODS or nonsurvival as determined by ROC analysis with a sensitivity and specificity of 93% and 88% for PCT and 40% and 100% for CRP, respectively (P < 0.01). The single or combined prediction of the two major complications was already possible on the third and fourth day after onset of symptoms with a sensitivity and specificity of 79% and 93% for PCT > or =3.8 ng/mL compared with 36% and 97% for CRP > or =430 mg/L, respectively (P = 0.002). CONCLUSION Monitoring of PCT allows early and reliable assessment of clinically relevant pancreatic infections and overall prognosis in AP. This single test parameter significantly contributes to an improved stratification of patients at risk to develop major complications.
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Affiliation(s)
- Bettina M Rau
- Department of General, Visceral, and Vascular Surgery, University of the Saarland, Kirrberger Strasse, 66421 Homburg/Saar, Germany.
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Gansauge F, Ramadani M, Schwarz M, Beger HG, Lotspeich E, Poch B. The clinical efficacy of adjuvant systemic chemotherapy with gemcitabine and NSC-631570 in advanced pancreatic cancer. Hepatogastroenterology 2007; 54:917-20. [PMID: 17591092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND/AIMS Recently we have shown that NSC-631570 (Ukrain) is a safe and effective drug in the treatment of unresectable pancreatic cancer. The aim of this study was to determine the effectiveness of the combined treatment with Gemcitabine and NSC-631570 in the adjuvant treatment of resected advanced pancreatic cancer. METHODOLOGY 30 patients received adjuvant chemotherapy following surgical resection for pancreatic cancer. Chemotherapy consisted of Gemcitabine according to the Burris-protocol with weekly infusions of 1000 mg/sqm. Immediately following Gemcitabine infusion 20mg of NSC-631570 were administered intravenously over 15 minutes. RESULTS WHO grade II toxicities were observed in 53%, no WHO grade III or IV toxicities occurred. In 80% of the patients recurrence of the disease was observed. The relapse-free survival time was 21.7 months. The actuarial survival rates were 86.7% after one year, 76.6% after two years, 46.7% after three years and 23.3% after five years. The median survival time according to Kaplan-Meier regression analysis was 33.8 months. CONCLUSIONS Adjuvant chemotherapy in advanced stages of pancreatic cancer using the combination of Gemcitabine and NSC-631570 is a safe treatment and seems to lead to a prolonged survival. Although further investigation is needed to confirm these results, the combined treatment of Gemcitabine and NSC-631570 is a promising therapy for the adjuvant treatment of resectable advanced pancreatic cancer.
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Affiliation(s)
- Frank Gansauge
- Center for Oncological, Endocrinological and Minimal-access Surgery, University of Ulm, Silcherstr. 36, 89231 Neu-Ulm, Germany.
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Schwarz M, Poch B, Isenmann R, Kriese D, Rozdzinski E, Beger HG, Gansauge F. Effect of early and late antibiotic treatment in experimental acute pancreatitis in rats. Langenbecks Arch Surg 2007; 392:365-70. [PMID: 17380347 DOI: 10.1007/s00423-007-0166-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 02/01/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND The clinical course in acute necrotizing pancreatitis is mainly determined by bacterial infection of pancreatic and peripancreatic necrosis. The effect of two antibiotic regimens for early and late treatment was investigated in the taurocholate model of necrotizing pancreatitis in the rat. MATERIALS AND METHODS Seventy male Wistar rats were divided into five pancreatitis groups (12 animals each) and a sham-operated group (10 animals). Pancreatitis was induced by intraductal infusion of 3% taurocholate under sterile conditions. Animals received two different antibiotic regimes (20 mg/kg imipenem or 20 mg/kg ciprofloxacin plus 20 mg/kg metronidazole) early at 2, 12, 20, and 28 h after induction of pancreatitis or late at 16 and 24 h after induction of pancreatitis or no antibiotics (control). Animals were examined after 30 h for pancreatic and extrapancreatic infection. RESULTS Early and late antibiotic treatment with both regimes could significantly reduce pancreatic infection from 58 to 8-25%. However, extrapancreatic infection was only reduced by early antibiotic therapy. While quinolones also reduced bacterial counts in small and large bowel, imipenem did not. CONCLUSIONS In our animal model of necrotizing pancreatitis, early and late treatment with ciprofloxacin/metronidazole and imipenem reduce bacterial infection of the pancreas. Extrapancreatic infection, however, is reduced significantly only by early antibiotic treatment. The effectivity of early antibiotic treatment in the clinical setting should be subject to further investigation with improved study design and sufficient patient numbers.
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Affiliation(s)
- Michael Schwarz
- Department of General Surgery, University of Ulm, Ulm, Germany.
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Rau BM, Frigerio I, Büchler MW, Wegscheider K, Bassi C, Puolakkainen PA, Beger HG, Schilling MK. Evaluation of procalcitonin for predicting septic multiorgan failure and overall prognosis in secondary peritonitis: a prospective, international multicenter study. ACTA ACUST UNITED AC 2007; 142:134-42. [PMID: 17309964 DOI: 10.1001/archsurg.142.2.134] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
HYPOTHESIS Infections and sepsis are major complications in secondary peritonitis and still represent a diagnostic challenge. We hypothesized that the laboratory marker procalcitonin would provide an early and reliable assessment of septic complications. DESIGN Prospective, international, multicenter inception cohort study. SETTING Five European surgical referral centers. PATIENTS Eighty-two patients with intraoperatively proven secondary peritonitis were enrolled within 96 hours of symptom onset. MAIN OUTCOME MEASURES Procalcitonin and the laboratory routine marker C-reactive protein (CRP) were prospectively assessed and monitored for a maximum of 21 consecutive days. RESULTS Procalcitonin concentrations were most closely correlated with the development of septic multiorgan dysfunction syndrome (MODS), with peak levels occurring early after symptom onset or during the immediate postoperative course. No such correlation was observed for CRP. According to receiver operating characteristic analysis, a procalcitonin value of 10.0 ng/mL or greater on 2 consecutive days was superior to a CRP level of 210 mg/L or greater for predicting septic MODS, with sensitivity, specificity, and positive and negative predictive values of 65%, 92%, 83%, and 81% for procalcitonin and 67%, 58%, 49%, and 74% for CRP, respectively (P<.001). Assessment of septic MODS was already possible on the first 2 postoperative days, with similar sensitivity and specificity. Persisting procalcitonin levels greater than 1.0 ng/mL beyond the first week after disease onset strongly indicated nonsurvival and were significantly better than CRP in assessing overall prognosis (P<.001). CONCLUSIONS Procalcitonin monitoring is a fast and reliable approach to assessing septic MODS and overall prognosis in secondary peritonitis. This single-test marker improves stratification of patients who will develop clinically relevant complications.
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Affiliation(s)
- Bettina M Rau
- Department of General, Visceral, and Vascular Surgery, University of the Saarland, Homburg/Saar, Germany.
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Poch B, Lotspeich E, Ramadani M, Gansauge S, Beger HG, Gansauge F. Systemic immune dysfunction in pancreatic cancer patients. Langenbecks Arch Surg 2007; 392:353-8. [PMID: 17235586 DOI: 10.1007/s00423-006-0140-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Accepted: 11/27/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS We investigated the immune status in 32 pancreatic cancer patients (PC) in comparison with healthy controls (HC). MATERIALS AND METHODS Using flow cytometry, peripheral blood lymphocytes (PBL) were characterized by the expression of surface markers for T helper cells (CD4), T suppressor cells (CD8), B cells (CD19) and NK cells (CD56). The blastogenic response of PBL was analyzed after stimulation with concavalin A (ConA), phytohemagglutinin (PHA), pokeweed mitogen (PWM) and anti-CD3 antibodies. The serum levels of TNF-alpha, IL-1beta, IL-2, IL-10, IL-12, IL-18, IL-1RA, sIL-2R and TGF-beta were determined by ELISA. RESULTS No differences in the distribution of peripheral immunocytes in PC were found, whereas the blastogenic response of peripheral blood lymphocytes (PBL) after stimulation with PHA or anti-CD3 antibodies was significantly decreased in PC. In PC, we found reduced serum levels of IL-2 and significantly elevated levels of TNF-alpha, TGF-beta1, IL-10, IL-2R, IL-1beta and IL-1RA. CONCLUSION These data provide evidence for a systemic immune dysfunction in pancreatic cancer patients characterized by a shift towards a T helper cell type 2 cytokine profile, a significant elevation of substances related to T cell suppression and a reduced blastogenic response to PHA and anti-CD3 antibodies of PBL.
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Affiliation(s)
- Bertram Poch
- Center for Oncological, Endocrinological and Minimal-access Surgery, Silcherstr. 36, 89231 Neu-Ulm, Germany
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Rau BM, Krüger CM, Hasel C, Oliveira V, Rubie C, Beger HG, Schilling MK. Effects of immunosuppressive and immunostimulative treatment on pancreatic injury and mortality in severe acute experimental pancreatitis. Pancreas 2006; 33:174-83. [PMID: 16868484 DOI: 10.1097/01.mpa.0000226895.16817.a1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Acute pancreatitis is associated with substantial alterations of the immunologic host response which has been claimed to promote remote organ dysfunction, septic complications, and mortality. Treatment with immunomodulating substances has been subject of few experimental studies with still conflicting results. METHODS We used the taurocholate-induced model of severe acute pancreatitis (SAP) in rats which were assigned to different treatment regimen: isotonic saline (SAP-S) for nontreated controls, recombinant rat interferon-gamma for immunostimulation (SAP-IFN-gamma), and FK506 for immunosuppression (SAP-FK506). Animals were killed after 3, 6, and 24 hours as well as 3 and 7 days, and parameters of local and systemic severity were assessed. RESULTS Treatment with IFN-gamma and FK506 attenuated the progression of intrapancreatic necrosis within the first 24 hours after pancreatitis induction along with a substantial reduction of subsequent neutrophil tissue infiltration as shown by decreased myeloperoxidase activity. Enhanced cell death by apoptosis during the postacute course was reduced in FK506-treated animals only. Pancreatic interleukin (IL) 1beta messenger RNA up-regulation occurred early and was slightly suppressed in both treatment groups; tumor necrosis factor alpha (TNF-alpha) and IL-2 messenger RNA expression paralleled the onset of apoptosis and was markedly decreased in IFN-gamma- and FK506-treated rats. The 2 therapeutic regimens had similar effects on intrapancreatic and systemic IL-1beta and TNF-alpha protein release; however, the profiles of both cytokines were differently influenced. Whereas IFN-gamma and FK506 treatment lead to an enhanced intrapancreatic and systemic TNF-alpha protein release during the early course, IL-1beta concentrations were significantly reduced within the late intervals. Seven-day mortality was 44% in saline-, 29% in IFN-gamma-, and 25% in FK506-treated rats (P = not significant). CONCLUSIONS Severe acute pancreatitis is associated with early alterations of the immune response comprising overt T-cell activation and impaired monocyte/macrophage function alike. Targeting either immunologic derangement improves local pancreatic damage and systemic severity. However, because mortality was not improved, a therapeutic benefit of immunomodulating substances in clinical SAP remains to be defined.
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Affiliation(s)
- Bettina M Rau
- Department of General, Visceral, and Vascular Surgery, University of the Saarland, Homburg/Saar, Germany.
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Rau BM, Bothe A, Kron M, Beger HG. Role of early multisystem organ failure as major risk factor for pancreatic infections and death in severe acute pancreatitis. Clin Gastroenterol Hepatol 2006; 4:1053-61. [PMID: 16843734 DOI: 10.1016/j.cgh.2006.05.030] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infection of necrosis is considered as principal determinant of outcome in necrotizing pancreatitis and as potential complication after operative treatment of sterile necrosis. In this report a new concept is proposed. METHODS Of 392 patients with necrotizing pancreatitis, 135 patients with operatively treated sterile necrosis were stratified into 3 postoperative entities: secondary pancreatic infections (PIN, group I), pancreatic contaminations (group II), and sterile courses (group III). Ninety-five patients with conservatively treated sterile necrosis (group IV) served as controls. RESULTS Secondary PIN developed in 64 (47%) patients and contaminations in 37 (27%) patients, whereas 34 (25%) patients remained sterile postoperatively. Secondary PIN and contaminations were both diagnosed after a median of 3 weeks after disease onset. Early/preoperative multisystem organ failure (MODS) affecting >2 organs was more frequent in group I (35%) than in group II (5%), group III (12%), and group IV (7%) (P < .003); mortality rates were 38%, 3%, 21%, and 7%, respectively (P < .001). Multiple logistic regression identified early/preoperative MODS and extent of intrapancreatic necrosis as major risk factors to develop secondary PIN in operatively treated sterile necrosis. However, irrespective of operative or conservative treatment, only early onset MODS >2 organs proved to be the predominant risk factor for death. CONCLUSIONS Early MODS and extended intrapancreatic necrosis are risk factors for secondary PIN after operative treatment of sterile necrosis. In contrast, the ultimate outcome strongly depends on early and high systemic illness, whereas local pathology and operative procedure seem to be less important.
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Affiliation(s)
- Bettina M Rau
- Department of General, Visceral, and Vascular Surgery, University of the Saarland, Homburg/Saar, Germany.
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Beger HG, Rau BM. Randomized controlled clinical trials—support but not substitute of decision-making in surgery. Langenbecks Arch Surg 2006; 391:301-3. [PMID: 16761163 DOI: 10.1007/s00423-006-0062-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 05/16/2006] [Indexed: 10/24/2022]
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Beger HG, Arbogast R. The art of surgery in the 21st century: based on natural sciences and new ethical dimensions. Langenbecks Arch Surg 2006; 391:143-8. [PMID: 16570205 DOI: 10.1007/s00423-006-0039-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 02/24/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIMS In the future, new surgical techniques will only be introduced in clinical practice if evidence-based results--frequently the results of controlled clinical trials--are presented. Unlike any other medical discipline, surgeons provide their diagnostic and operative skills through the surgeons' hand and the use of technical equipment, which ranges from instruments and devices employed during operation to the use of surgical robots. RESULTS Analysing the fundaments of surgery on the turn of the century, there is only a little doubt about the increasing impact of data deriving from natural sciences on knowledge in medicine and management of diseases. The natural scientific method of detecting, measuring, and verifying facts is the methodological basis of surgery as well. The autonomy of the surgeon's clinical decision making is significantly restricted by the definition of guidelines. They shift the decision from a single patient to a collective panel. Patient safety and the efficiency of new treatment modalities compared with previous standards are the criteria for the judgement of innovative surgery today. The communication and interaction between surgeon-scientist and patients is guaranteed legally by written consensus. But beside of the high probability of benefit from therapy and written consensus, the surgeon-patient relation is determined by these factors: limitation of time for care of an individual patient, increase of time for administration and documentation, increase of bureaucratic barriers for medical research, and health cost constraints. CONCLUSION The medical mandate to cure a sick patient is an individual mandate to take action. Measures, numbers, and images are only preconditions for a surgeon's action in daily clinical work; they can never replace it. The call for an ethical imperative in scientific surgery that is dependent on technology is justified when the state of science and uncritical use of surgical skills and financial constraints have major impact on providing medical care.
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Affiliation(s)
- H G Beger
- University of Ulm, Steinhoevelstrasse 9, 89075, Ulm, Germany.
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Schlosser W, Siech M, Beger HG. Pseudocyst treatment in chronic pancreatitis--surgical treatment of the underlying disease increases the long-term success. Dig Surg 2005; 22:340-5. [PMID: 16293964 DOI: 10.1159/000089769] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2003] [Accepted: 08/05/2005] [Indexed: 12/10/2022]
Abstract
BACKGROUND For reasons of persisting controversies concerning indications for surgery, we evaluated chronic pancreatitis patients following pancreatic head resection or drainage procedure for pseudocysts located in the pancreatic head. MATERIAL AND METHODS 206 patients (166 male, 40 female) with chronic pancreatitis and pseudocysts in the pancreatic head were operated between April 1982 and July 2001. 169 patients (82%) were treated with the duodenum-preserving pancreatic head resection, a pseudocyst-jejunostomy was performed in 37 patients (18%). RESULTS The hospital mortality was 0.4%. The late mortality was 19% in a median follow-up of 7.3 years. The rate of patients with complete relief of pain was significantly higher after resection compared to drainage procedure in the long-term follow-up (94 vs. 75%; p = 0.003). With regard to recurrence of pseudocysts, patients had an elevated rate of reoperations following drainage procedure (13 vs. 1%; p = 0.008). The endocrine function was significantly better preserved in patients of the drainage group compared to the resection group (no diabetes 67 vs. 35%, p < 0.01). CONCLUSION The resection has, compared to drainage procedures alone, the advantage of low recurrence rate of pseudocysts and a high rate of pain-free patients in the long-term follow-up. However, the risk of diabetes is increased in the resection group.
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Rau B, Bothe A, Beger HG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 2005; 138:28-39. [PMID: 16003313 DOI: 10.1016/j.surg.2005.03.010] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center. METHODS Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001). RESULTS Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis. CONCLUSIONS Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.
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Affiliation(s)
- B Rau
- Department of General, Visceral and Vascular Surgery, University of the Saarland, Germany
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Schlosser W, Rau BM, Poch B, Beger HG. Surgical treatment of pancreas divisum causing chronic pancreatitis: the outcome benefits of duodenum-preserving pancreatic head resection. J Gastrointest Surg 2005; 9:710-5. [PMID: 15862268 DOI: 10.1016/j.gassur.2004.11.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 10/25/2004] [Accepted: 11/18/2004] [Indexed: 01/31/2023]
Abstract
Pancreas divisum (PD) represents a duct anomaly in the pancreatic head ducts, leading frequently leading to recurrent acute pancreatitis (rAP) or chronic pancreatitis (CP). Based on endoscopic retrograde cholangiopancreatography, pancreas divisum can be found in 1% to 6% of patients with pancreatitis. The correlation of this abnormality with pancreatic disease is an issue of continuing controversy. Because of the underlying duct anomalies and major pathomorphological changes in the pancreatic head, duodenum-preserving pancreatic head resection (DPPHR) offers an option for causal treatment. Thirty-six patients with pancreatitis caused by PD were treated surgically. Thirty patients suffered from CP, 6 from rAP. The mean duration of the disease was 47.5 and 49.8 months, respectively. The age at the time of surgery was 39.2 years in the CP group, and 27.6 years in the rAP group. Median hospitalization since diagnosis was 18.8 weeks for CP patients and 24.6 weeks for rAP patients. Previous procedures performed in these patients included endoscopic papillotomy (30%), duct stenting (14%), and surgical treatment (17%). The median preoperative pain score was 8 on a visual analog scale. According to the classification of pancreas divisum, 10 patients demonstrated a complete PD, 25 had a functionally incomplete PD, and 1 had a dorsal duct type. The pain status as well as the endocrine (oral glucose tolerance test) and exocrine (pancreolauryl test) function were evaluated preoperatively and early and late postoperatively with a median follow-up time of 39.3 months. There was no operative-related mortality. The follow-up was 100%; 4 patients died (1 from suicide, 1 from cardiac arrest, and 2 from cancer of the esophagus). Fifty percent of the patients were completely pain-free, 31% had a significant reduction of pain with a median pain score of 2 (P < 0.001). Six patients (5 CP, 1 rAP) had further attacks of acute pancreatitis with a need for hospitalization. DPPHR reduced pain and preserved the endocrine function in the majority of patients with pancreas divisum. Therefore, DPPHR is an alternative to other resective or drainage procedures after failure of interventional treatment.
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Affiliation(s)
- W Schlosser
- Department of General Surgery, University of Ulm, Ulm, Germany
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Beger HG. 'Understanding the development of pancreatic cancer will emerge from basic research'. An interview with Prof. Hans G. Beger. Interviewed by Martin E. Fernandez-Zapico. Pancreatology 2005; 5:116-8. [PMID: 15849482 DOI: 10.1159/000085262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Prof. Hans Beger is a worldwide-recognized pancreatologist in the treatment of pancreatic diseases. He led the way in pancreatic surgery with the development of a classic intervention: the Beger procedure for the treatment of chronic pancreatitis. In this interview for Pancreatology Prof. Beger shares his life experiences as a scientist in pancreatic research.
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Abstract
Severe acute pancreatitis is considered to be a subgroup of acute pancreatitis with the development of local and/or systemic complications. A significant correlation exists between the development of pancreatic necrosis, the frequency of bacterial contamination of necrosis and the evolution of systemic complications. Bacterial infection and the extent of necrosis are determinants for the outcome of severe acute pancreatitis. The late course of necrotizing pancreatitis is determined by bacterial infection of pancreatic and peripancreatic necroses. Mortality increases from 5-25% in patients with sterile necrosis to 15-28% when infection has occurred. The use of prophylactic antibiotics has been recommended in patients with necrotizing pancreatitis. Several controlled clinical trials demonstrated a significant reduction in pancreatic infections or a significant reduction of hospital mortality. However, the results of these clinical trials are controversial and not convincing. Recently, the largest randomized placebo-controlled, double-blind trial has been able to demonstrate that antibiotic prophylaxis with ciprofloxacin and metronidazole has no beneficial effects with regard to the reduction of pancreatic infection and the decrease of hospital mortality. The clinical data from this placebo-controlled trial do not support antibiotic prophylaxis in all patients with necrotizing pancreatitis, but in specific subgroups of patients with pancreatic necrosis and a complicated course.
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Affiliation(s)
- H G Beger
- Department of Surgery, University of Ulm, Ulm, Germany.
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