Pancreatic head mass: what can be done? Classification: the clinical point of view.

Surgeons frequently find pancreatic head mass when operating. The obvious difficulty is to make the correct preoperative differential diagnosis between chronic pancreatitis and pancreatic tumor. The first step is to reach a diagnosis, with some certainty, prior to the operation. The second step in the case of a tumor is the accurate staging and deciding whether or not it is resectable. On the one hand, time and cost must be considered; on the other hand, the therapy must be decided. Obtaining information about the characteristics of the pancreatic disease (nature, size, exact location) and establishing the tissue diagnosis preoperatively may simplify the decision to operate and the operation itself. In the case of chronic pancreatitis, the aim of the operation is to eliminate pain and other symptoms, while in the case of cancer, the purpose is to remove the malignant tissue. In most patients, it is possible to identify the disease on the basis of previous examinations together with preoperative diagnostic techniques such as exploration, palpation and fine-needle aspiration biopsy. Chronic pancreatic head mass should be operated upon with Beger s or Frey s procedure while pancreatic head tumors should be treated by means of head resection with the aim of preserving the pylorus or the Whipple procedure may be used. When the diagnosis is in doubt, a radical approach is thought to be best. Our conclusion is that there is no diagnostic method capable of making a definitive differential diagnosis as to the nature of the pancreatic head mass. Further study is required as to the extent to which differential diagnosis should be investigated.

Pancreatic head mass: how can we treat it? Tumor: surgical treatment.

Pancreatic carcinoma is a devastating disease. Untreated 5-year survival is 0%. The only possibility of being cured is given by surgical removal of the tumor. Pancreatoduodenectomy previously involved high morbidity and mortality rates until it was postulated that palliation gave better results. Today, morbidity and mortality rates have been decreased to an acceptable level, mortality rates in specialized centers being under 5%. Prognostic factors determining survival were found to be the size of the tumor, grade, lymph node involvement and stage. In order to be able to compare results of the different centers, standardization of the surgical technique is mandatory. It is unanimously accepted that in order to improve survival in pancreatic carcinoma, the radicality of the surgical procedure should be increased to include lymphadenectomy. Postoperative adjuvant therapy could also be a determinant factor. Prospective randomized clinical trials will give an answer to these still unanswered questions.

[Antibiotic prophylaxis for high risk patients undergoing cholecystectomy]. / Fokozott kockázatú epemútétek antibiotikum profilaxisa.

An open, randomised clinical trial was performed on 435 high risk patients who underwent open cholecystectomy between 1 = January 1993. and 31. December 1995. The patients were divided into three groups. Group 1 (AMOX/CLAV, N = 179) was treated with 1.2 g i.v. amoxicillin/clavulanic acid, the patients in Group 2 (COMPARATOR, N = 164) were given other antibiotics commonly used for prophylaxis in biliary surgery (cefamandole, cefuroxime, cefotaxim). Group 3 (CONTROL, N = 92) contained patients without any risk factors for infectious complication. In this group we did not use antibiotic prophylaxis. The results were analysed with Student t, and x2 methods. The wound infection rate in Group 1 was 2.76% versus 5.48% in Group 2. The difference was significant if the patients were older than 65 years or the preoperative hospitalisation was longer than 5 days. The concentration of amoxycillin/calavulanic acid was measured in the serum, in the wall of the gall bladder, in the bile obtained both from the gall bladder and the major bile duct. The observed levels were higher than the therapeutic concentration in the serum and in the bile gained from the major bile duct, whereas lower in the gall bladder wall, and in the bile gained from the gall bladder. Systemic antibiotic prophylaxis is required for open cholecystectomy in high risk patients.

[Comparative study of meropenem and amikacin/metronidazole combination in the treatment of severe abdominal surgical infections]. / A meropenem és az amikacin/metronidazol kombináció összehasonlító vizsgálata súlyos, sebészeti hasi fertözések kezelésében.

The authors compared in a prospective, randomized study the efficacy of amikacin/metronidazole combination and meropenem monotherapy in serious, intra-abdominal infections needing surgical treatment. There were 31 evaluable patients. Fifteen patients were involved to the meropenem and 16 to the combination group. The average age were 46 years in the meropenem group and 50 in the other one, the APACHE II score was similar (12.9 and 12.5). Among the examined parameters, only the white blood cell number decrease showed significant difference between the study groups. In the meropenem group 5.05 x 10(9), while in the comparator group 3.57 x 10(9) (p < 0.01). At the end of the study period, the infection was cured in the case of 11 patients in the meropenem and 9 patients in the control-group. At the end of the treatment the average APACHE II score decreased to 7.6 and to 9.6 points respectively. Clinically both therapies proved to be effective and well tolerated but the microbiological assessment revealed that meropenem tended to cover all pathogens of the mostly polymicrobial infections (12 cases, 43%) more frequently, than amikacin/metronidazole combination (9 cases, 33%). The Gram negative bacteria showed sensitivity to both meropenem and amikacin, but their majority were inhibited by meropenem at a concentration 1 or 2 orders of magnitude lower, than by amikacin. The therapeutic dose of meropenem is not toxic; therefore, it can be safely administered in poor general condition, frequently with renal impairment. We did not observed serious adverse event during the study period.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study.

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

[Risk factors of infected pancreatic necrosis, its microbiology and antibiotic treatment]. / A fertözödött pancreasnecrosis kockázati tényezöi, mikrobiológiája és antibiotikus kezelése.

Acute pancreatitis is associated with greater and smaller necrosis in 20% of the cases. The lethality rate of sterile and infected necrosis is 10 and 15-40%, respectively. The results of a retrospective and a prospective study in acute pancreatitis have been analyzed in this study. Twenty patients suffering from infected necrosis due to acute necrotising pancreatitis were selected into the retrospective study. They were divided into two groups: Group 1 (N = 10) survivors, Group 2 (N = 10) those who died. The fate of patients was determined by their age, the severity of pancreatitis, and the effectiveness of the operation. In a prospective study 63 patients were operated due to benign pancreatic disease with fluid collection. Microbiological samples were taken during surgery in every case. It could be stated that the Enterobacteriaceae spp. play the principal role in the infection, and the anaerobic bacteria occur sporadically. The omission of bacteriological sample taking during surgery frustrates the targeted antibiotic treatment. The blood culturing may have useful contribution. The targeted antibiotic therapy based on relevant microbiological sample taking is substantial complementary of the surgical intervention in the treatment of the inflammatory pancreatic diseases.

Pancreatic pseudocysts associated with chronic pancreatitis--early and late results of 1367 operations.

The authors hereby review the data of 1367 operations for pancreatic pseudocysts. The surgical procedures of choice in particular pancreatic pathologies are analysed in the light of early morbidity and mortality, as well as long term follow-up results. The best operations for pancreatic pseudocysts have been the internal drainage procedures, which resolve the pathological alterations without the necessity of pancreatic resection. The treatment of chronic pancreatitis may require combined surgical procedure, such as cysto-Wirsungo-gastrostomy. The pancreatic resections performed for the treatment of small pseudocysts in the pancreatic head have been superseded by the less invasive blunt, forced cysto-duodenostomies, representing better results secondary to the smaller perioperative risk for the patient. The cyst-to-stomach and cyst-to-duodenum internal drainage techniques are just as effective, but with shorter operation time, than the Roux-en-Y cysto-jejunostomies.

[Papillary cystic neoplasms in the ectopic pancreas]. / Papillaris és cisztikus neoplasia ectopiás pancreasban.

The authors reported a case of a young woman. From her omentum a clinically and radiologically benign tumour was removed that had been observed for years and caused minor symptoms. Histologically the tumour proved to be a so called papillary and cystic tumour that originated from ectopic pancreatic tissue. The histological diagnosis was justified by immunohistochemical and electronmicroscopical examinations. Reports of this type of tumour evolving in an ectopic pancreas appeared only twice in the world literature to the knowledge of the authors.

The outcome of pancreatic fistulas developed after surgery for pancreatic pseudocysts.

Pancreatic fistulas (PF) develop in about 20% of cases operated for pancreatic pseudocysts. The authors analyse 81 cases of postoperative PF. These were formed following 991 operations performed for pancreatic pseudocysts (PPCs) in 850 patients from 1987 to 1992. It is concluded that the incidence of PF formation is significantly (P < 0.01) increased following interventions for acute-type pseudocysts and after external drainage. One-third of the fistulas closed spontaneously within 1-4 weeks, while another 1/3 persisted for 1-6 months before gradual closure. Closure of fistulas was facilitated by inhibition of pancreatic secretion with Somatostatin or endoscopic intervention (EST, endoprosthesis) in 24% of all cases. Only 15% (14 cases), of the fistulas, i.e. 1% of total patients, required surgery. The procedure of choice in the 14 cases was exstirpation of fistulas alone (2 cases) or combined with necrectomy (10 cases), or with distal pancreatic resection (2 cases). In cases of drained pancreatic fistulas observation can be an appropriate treatment option, while long-standing fistulas producing large amounts require intervention.

[Initial experience with ESWL therapy of pancreatic duct calculi]. / A pancreas vezetékkövek lökéshullám (ESWL) kezelésének kezdeti tapasztalatai.

Extracorporeal shock wave lithotripsy of pancreatic stones was performed in four patients with chronic pancreatitis and a dilated duct system harbouring stones 5-12 mm in diameter. The stones were disintegrated by shock waves using a Dornier lithotripter in one or more sessions. Disintegration of stones was achieved in 4/4 patients, initial (6-11 months) relief of pain in 3/4 patients, and total clearance of pancreatic duct in 3/4 patients. No complications were observed. In the first patient in whom ESWL was not completely successful, underwent an operation: a longitudinal pancreato-gastrostomy and the stones were found completely disintegrated. From these early data they conclude that ESWL of pancreatic duct stones is a provisional new alternative for surgery in the treatment of chronic pancreatitis.

Isolated granulomatous disease of the stomach.

A case of isolated granulomatous gastritis observed in a 66-year-old female patient is reported. The gastric granulomatosis gave rise to pyloric stenosis, and at the first explorative laparotomy the change was misdiagnosed for an inoperable tumour. Gastroscopy then revealed the presence of a peptic ulcer, which healed completely on drug therapy. At the second surgical intervention undertaken on account of a relapse after 2 years, Billroth II type resection of the stomach led to complete recovery; the patient has been free from complaints ever since. It is suggested that in addition to peptic ulcer and tumour, isolated gastric granulomatosis should be taken into consideration as the underlying mechanism of pyloric stenosis.

Respiration paralysing and circulatory effects of a new non-depolarizing relaxant, pipecurium bromide, in anaesthetized dogs.

The effect of a new sterane-structure, non-depolarizing muscle relaxant 2 beta,16 beta-bis(4'-dimethyl-1'-piperazino)-3 alpha,17 beta-diacetoxy-5 alpha-androstane dibromide (pipecurium bromide, RGH-1106, Arduan) was studied in 42 mongrel dogs under general anaesthesia (ether, halothane, methoxyflurane, thiobutobarbital, hydroxydione and dehydrobenzperidol-fentanyl (NLA II). Onset and duration of action and the presence of circulatory side effects were examined. It was found that the mean onset of respiration paralysing action was 156.1 s and apnea lasted for 38 min. In the thiobutobarbital group apnea lasted for 74 min. Arterial systolic blood pressure and central venous pressure did not change, but the heart rate was mildly decreased by pipecurium bromide. ECG intervals (PQ, QT and TP) did not change considerably, and the variations ran parallel with the prolongation of RR intervals due to the decrease of heart rate. Pipercurium bromide is a non-depolarizing muscle relaxant of medium duration, without any significant circulatory effects. Its duration of action was prolonged in the presence of thiobutobarbital, indicating a drug interaction between the two preparations.

First clinical experience with a new neuromuscular blocker pipecurium bromide.

The clinical trial of the new non-depolarizing muscle relaxant 2 beta,16 beta-bis-(4'-dimethyl-1'-piperazino)-3 alpha,17 beta diacetoxy-5 alpha-androstane dibromide (pipecurium bromide, RGH-1106, Arduan) was performed on 80 patients who had to undergo medium and major size intraabdominal operation on the basis of chronic surgical indication. Four types of general anaesthetic methods were applied, neuroleptanalgesia, halothane, halothane-fentanyl combination and hydroxydione. The clinical applicability of pipecurium bromide was tried to establish the dose needed for complete muscle relaxation initially and repeatedly and the effect of antagonist drugs on the muscle relaxation. We investigated the duration of the first and repeated dose of the relaxant. Heart rate and arterial blood pressure were measured, mean arterial pressure and pulse pressure were calculated. In 10 patients of the halothane group the behaviour of some haemodynamic parameters was investigated. The changes of acid base parameters, blood gases, serum electrolytes and blood sugar were also observed. The administered doses were initially 3.88 mg/h, repeated doses 2.32 mg/h, this means 0.052 mg/kg body weight initially and 0.026 mg/kg body weight repeatedly The duration of effect after the first dose was 53 min, after the repeated doses 45 min. There were no direct effects on heart rate and arterial blood pressure. It did not affect myocardial contractility or work function, there was no remarkable changes in cardiac output. There were no direct metabolic changes due to pipecurium bromide. The relaxant has no histamine releasing effect. At the end of the anaesthesia the effect can be antagonized with neostigmine. During our observations there were no side effects or allergic reactions caused by pipecurium bromide.

[Changes in the Na+, K+, and Ca++ concentrations in the urine in the course of surgical interventions]. / Anderungen der Na+-, K+- und Ca++- Konzentration im Harn im Laufe von chirurgischen Eingriffen.

The tests were carried out on 27 surgical patients. Diuresis and the Na, K and Ca concentrations in the urine were measured before, during and after operation. Due to operational stress and to the drugs used for general anaesthesia diuresis decreases progressively during operation and compared to the conscious state the amount of cations excreted during operations is significantly lower. Decrease of the serum potassium and calcium levels is not explained with the quantity of ions excreted with the urine.

[Changes in kidney function in abdominoperineal rectum excision under halothane anesthesia]. / Anderungen der Nierenfunktion bei abdominoperinealer Rektumexstirpation in Halothan-Narkose.

In 17 cases of abdomino-perineal rectum extirpation performed under combined intratracheal halothane anaesthesia, the volume of urine and the osmolality of serum and urine were determined. Though urinary volume decreased significantly, its osmolality did not rise. According to the operational stress this type of operation can be divided into an: 1) intra-abdominal and a 2) perineal phase. In the secretory and concentrating capacity of the kidney, again two phases can be distinguished. Owing to the great operational stress patients with deficient renal function often develop renal failure. It is stressed that such patients close observation, careful hydration prior to operation and the administration of diuretics are of particular importance.

The effect of surgery on carbohydrate metabolism. II. Insulin response during surgery.

Serum-immunoreactive insulin response on glucose load was observed during the operation of 13 patients. The tests were performed on the same patients also 5 days prior to operation. The patients were divided into two groups according to the performed operation which was either intra- or extraperitoneal. Glucose tolerance during operation remained unchanged, but the serum insulin level was considerably lower. A certain difference was detected between intraperitoneal and extraperitoneal operations in this respect, though the trend of the changes was the same. The probable pathomechanism of the lacking insulin secretion on glucose is discussed.