Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis

BACKGROUND

Total pancreatectomy and islet autotransplantation (TP/IAT) is a treatment option in a subset of patients with chronic pancreatitis. A systematic review of the literature was performed to evaluate the outcome of this procedure, with an attempt to ascertain when it is indicated.

METHODS

MEDLINE (1950 to present), Embase (1980 to present) and the Cochrane Library were searched to identify studies of outcomes in patients undergoing TP/IAT. Cohort studies that reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review.

RESULTS

Five studies met the inclusion criteria. The techniques reported for pancreatectomy and islet cell isolation varied between studies. TP/IAT was successful in reducing pain in patients with chronic pancreatitis. Comparing morphine requirements before and after the procedure, two studies recorded significant reductions. Concurrent IAT reduced the insulin requirement after TP; the rate of insulin independence ranged from 46 per cent of patients at 5 years' mean follow-up to 10 per cent at 8 years. The impact on quality of life was poorly reported. The studies reviewed did not provide evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis.

CONCLUSION

This systematic review showed that TP/IAT had favourable outcomes with regard to pain reduction. Concurrent IAT enabled a significant proportion of patients to remain independent of insulin supplementation.

Pilot study of personal, indoor and outdoor exposure to benzene, formaldehyde and acetaldehyde

There is a lack of data for health risk assessment of long term personal exposure to certain ubiquitous air pollutants present particularly in urban atmospheres. The relationship between ambient background concentrations and personal exposure is often unknown. A pilot campaign to measure indoor concentrations, outdoor concentrations and personal exposure to benzene, formaldehyde and acetaldehyde was conducted in a medium sized French town. A strong contribution to total personal exposure was observed from indoor sources, especially for formaldehyde and acetaldehyde, suggesting that indoor sources are dominant for these compounds. For benzene, the average personal exposure exceeded a 10 microgm(-3) limit value, although this was not the case for the ambient background concentration. For formaldehyde, the limit level was also exceeded. Observations suggest that true personal exposure cannot be determined directly from measurements pertaining from fixed ambient background monitoring stations. It is hoped that this will be taken into consideration by the bodies responsible for monitoring air pollution and the future European Air Quality Directive.

Personal goals and subjective well-being in later life

With a sentence completion technique, 708 elderly participants (65 to 90 years of age) expressed 15,027 personal aspirations. These goals were classified according to their motivational content in ten major categories and their relationships with various aspects of subjective well-being were studied. Two goal profiles emerged from this analysis. Aspirations centered on self-preservation were associated with poor self-rated physical health, being burden by difficulties, lack of meaning to life, dissatisfaction with life, and negative expectations for the future. Aspirations of self-development and interest in the well-being of others were associated with feelings of well-being in later life. Development of meaningful personal goals was discussed as as a new intervention approach with the elders.

Motivational goal objects in later life

With a sentence completion technique, 708 elderly participants (64 to 90 years of age) expressed 15,020 personal aspirations. These goals were classified according to their motivational content in ten major categories and their relationships with different sociodemographic variables were studied. Two goal profiles emerge from this analysis. Aspirations centered on self-preservation are associated with very old age, functional impairment, lower S.E.S. and education, being alone or institutionalized. Aspirations of self-development and interpersonal relationships are associated with younger age, physical autonomy, higher S.E.S. and education, being married or living at home. Development of meaningful personal goals are discussed as a mean of intervention with elderly individuals.

Intraluminal pressures during perfusion of the human colon in situ

Nine healthy human volunteers underwent colonic perfusion and recording of the intraluminal pressure simultaneously in the right, transverse, and left colon. Isotonic saline was infused into the caecum at various flow rates from 10 to 30 ml per min. During colonic perfusions, pressure waves were simple and distorted only by respiratory artifacts. Their amplitude was large (10 to 44 cm of H2O), of long duration (8 to 68 sec), and of low frequency (0.2 to 1.8 wave per min). The frequency of the waves was very stable and this stability was uninfluenced by the site of recording and the rate of perfusion. A pressure wave in the right colon was always followed within 3 sec by a wave in the transverse and left colon. The frequency and amplitude of the waves increased in all subjects and at all rates of perfusion from right to left colon (P less than 0.001). The wave frequency increased with the perfusion flow rate (P less than 0.001). The relationship between the perfusion flow rate and the waves amplitude was curvilinear (P less than 0.01). It is concluded that in the human colon perfused in situ there is a gradient of motility preventing aboral propulsion. This study suggests that during perfusion, liquids are trapped in the right colon. Data on transport of water and electrolytes, obtained from whole colon perfusion, may in fact reflect events occurring in the proximal part of the large bowel.

Intestinal peptidase activity following whole-body irradiation in mice

Dipeptidase activity (Gly-L-Leucine, L. Leu-Glycine, Gly-L-Phe, L Phe-Gly) was measured in the cytoplasmic fraction of the small bowel mucosa of mice eating three synthetic, defined formula, diets or Purina Chow. The activity/milligram protein of all peptidases was found to be reduced seven days after the last of six weekly exposures to 400 rads (Cobalt 60). The magnitude of reduction varied from half the control value for L-Leu-Glycine peptidase to between one fourth and one fifth the control values for the other three peptidases. These findings may partly explain the improved tolerance to radiation in mice eating a diet containing amino acids (protein hydrolysate) instead of whole protein.

Dietary protection during radiation therapy

Eighteen patients receiving Cobalt 60 irradiation for abdominal or pelvic malignancies were assigned at random to eat either a semi-hydrolyzed diet (Flexical: 10 g % casein hydrolsate; 14 g % triglycerides, 20% of which medium chain; 66% disaccharides) or a normal diet. There are no significant differences between these two groups with respect to age and the ratio of ideal to actual caloric intake. The patients in the control group received on the average a total of 3900 rd and those in the Flexical group 4040 rd. Generally, Flexical appeared to have a significant positive effect on body weight. In addition, radiation-induced diarrhea was not a problem in the Flexical group. In the latter group, serum proteins including immunoglobulins remained essentially unchanged during therapy while a moderate but significant fall was observed in all control patients. No significant difference between the two groups was observed with respect to peripheral blood hematocrit, red and white cell counts. However, the drop in blood lymphocytes following irradiation was significantly less in the Flexical group. The mechanisms of radioprotection are discussed. These preliminary data indicate that the nutritional and perhaps the immunological status of cancer patients receiving intensive irradiation can be maintained by dietary measures.