Limited surgery for benign tumours of the pancreas: a systematic review.

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.

[Pancreatic surgery in a regional hospital]. / Pankreaschirurgie an einem Krankenhaus der Grund- und Regelversorgung.

BACKGROUND: Recently it was shown that in several surgical procedures the case load of an institution correlated in direct proportion with the outcome. Therefore, the German authorities with effect from January 1, 2008 have defined the minimum case load per year of an institution for selected surgical procedures in order to increase the medical quality and improve the outcome. Until now, however, there is no experience in establishing a medical centre for pancreatic surgery according to these regulations. The aim of this study was, therefore, to describe the possibilities and the prerequisites necessary to establish a new pancreatic centre according to the requirements of the German official regulations. PATIENTS AND METHODS: In a prospective clinical study, the data of 269 patients who underwent a resective surgical procedure for pancreatic diseases between May 1998 and August 2007 were analysed. All included patients underwent a defined surgical procedure for malignant and benign lesions of the pancreatic gland. Indication for operation, operative procedure, postoperative morbidity and mortality were analysed in this study. RESULTS: After the year 2000, the annual case load of pancreatic resections per year amounted to over 30 patients. In most cases (n = 127) the indication for operation was a malignant disease of the pancreatic head, in 94 cases the patients were operated for chronic pancreatitis with a benign tumour of the pancreatic head. In most cases (n = 106) a pylorus-preserving partial duodenopancreatectomy was performed followed by the duodeno-preserving pancreatic head resection (Beger procedure, n = 55). The overall complication rate amounted to 30.2 %, overall mortality 0.7 %. Two patients died on the 37 (th) and 44 (th) day postoperatively. CONCLUSIONS: The establishment of a medical centre for pancreatic surgery is possible according to the regulations of the German authorities. Nevertheless, there are multiple factors influencing medical quality apart from the case load of a hospital. These are a well-functioning intensive care unit and the possibility for radiological and/or gastroenterological interventions 24 hours a day. Most important is the personal motivation of the doctors and nurses in successfully supporting such a programme. So far the prospective implication on health care or medical education cannot be finally anticipated. The different independent factors of medical quality concerning pancreatic surgery have still to be identified and should reasonably influence any governmental or institutional regulations.

["Fast-track" and elective, laparoscopic colo-rectal surgery]. / "Fast-track" und elektive laparoskopische Eingriffe am Kolorektum.

UNLABELLED: The aim of this prospective clinical evaluation was to investigate the influence of "Fast-track"-treatment in patients undergoing laparoscopic colorectal operations and its effect on morbidity, hospital stay and recovery. PATIENTS AND METHODS: Bowel cleaning under enteral hypercaloric nutrition (Biosorb Energie, Fa. Nutricia, Germany) was achieved with Fleet (Ferring Arzneimittel, Germany) one day prior to surgery. A peridural catheter was placed preoperatively. Intraoperative electrolyte substitution should not exceed 12 ml/kg KG/h. In case of decreasing intraoperative blood pressure hydroxyethylstarch 6% was substituted. The nasogastric tube was removed immediately after the operation, the urinary catheter was removed on the first postoperative day. The patients stayed on the intermediate care department for one night and started already there with oral feeding and mobilisation (for 2 h). The following days mobilisation increased to 4 h daily under normal enteral nutrition without infusions. RESULTS: Between June 2003 and January 2006, 147 patients undergoing elective colorectal surgery were included in this study. Diverticulitis (n = 114), malignant tumors of the sigmoid colon (n = 6) or rectal cancer (n = 13), colonic adenomas (n = 5), stenotic Crohn's disease (n = 4) and small bowel carcinoid (n = 1), rectal prolaps (n = 1) and elongated colon sigmoideum (n = 4) were indications for surgical treatment. Laparoscopic sigmoid resection (n = 117), left hemicolectomy (n = 11), ileocecal resection (n = 8), anterior resection with total mesorectal excision (n = 9), abdomino-perineal exstirpation (n = 1) and anterior-segmental resection of the rectum (n = 1) were performed. Drainages were removed on the 2nd, peridural catheter on the 3rd postoperative day. Defecation occurred in all patients until the 2 (nd) postop. day. Early postoperative complication rate was 15% (22/147 patients) without mortality. 8 patients (5%) with anastomotic leakage were reoperated. The mean hospital stay was 6 days. The re-admission rate was 3% (4/147 patients) and included one patient with anastomotic leakage. CONCLUSION: "Fast-track"-treatment in combination with minimal-invasive surgery is a safe and comfortable perioperative treatment for patients with elective colorectal operations.

The influence of oxygenated water on the immune status, liver enzymes, and the generation of oxygen radicals: a prospective, randomised, blinded clinical study.

BACKGROUND & AIMS: Oxygenated water with an oxygen concentration of 30-120 mg/l water is believed to improve the immune status, without any toxicological effects. The purpose of this clinical study was to assess the effects of long-term drinking of oxygenated water on the immune status. METHODS: In this prospective, double-blinded, randomised study 24 volunteers of either sex (age 18-63 years) drank daily 3 times 500 ml either oxygenated (Verum-group: n=12) or normal mineral water (Placebo-group: n=12) for 28 days. On day 1 and day 28 standard laboratory tests, IgG, IgA and IgM, lymphocyte subpopulations and functional analysis of T-cells by flow cytometry, were done. Furthermore, the oxygen radicals were determined by the detection of the ascorbyl radicals. RESULTS: Drinking of normal or oxygenated water had no effect on whole blood count or the liver enzymes. Interestingly the volunteers in the Verum-group showed a significant increase in ascorbyl radicals after drinking oxygenated water for 14 and 21 days. CD4+ and CD4+CD45RA+ lymphocytes as well as lymphocyte activation marker (CD69) and soluble IL-2 receptor increased in both groups, in contrast T-helper2 cells and IgG decreased during the study. The only differences between the two groups were a significant decrease of NK-cells form 13.42%+ or -5.04 to 10.83%+ or -4.82 (P<.002) and an increase of the Th1/Th2-ratio from 2.77%+ or -1.07 to 6.68%+ or -5.33 (P<.03) in the Verum-group. CONCLUSION: Long-term consumption of oxygenated water has no apparent harmful effect on the liver, blood and the immune system. Moreover it leads to a transient moderate increase of oxygen radicals in the blood. An interesting observation is the increase of the Th1/Th2-ratio in the Verum group, whereas in both groups T-cell activation after mitogen stimulation, the soluble IL-2 receptor, the CD4+ and the naive CD4+CD45RA+ cells increased.

Regional celiac artery infusion in the adjuvant treatment of pancreatic cancer.

UNLABELLED: We performed adjuvant celiac artery infusion in pancreatic cancer, to find out whether this treatment prolongs survival and changes the biology of the disease after resection, especially by reducing liver metastasis. PATIENTS AND METHODS: Thirty-one patients received cyclic celiac artery infusions (CAI) after resection of their pancreatic cancer (27 ductal, 4 cystadenocarcinoma). The treatment consisted of 6 cycles (1 cycle = 5 days treatment) intra-arterial infusion using Seldingers technique with mitoxantrone A (Novantron) 10 mg/m2 d1, 5-fluorouracil + folinic acid 600 mg/m2 + 170 mg/m2 d2-d4 and cis-platinum 60 mg/m2 d5. Four to 5-week intervals between each cycle of chemotherapy were scheduled. The patients were monitored for toxicity, development of disease progression and survival. RESULTS: The median survival time was 21 months. During an observation period of 19 months, 70% of the patients developed disease progression. In 50% of cases the progression was local, in 40% intraperitoneal while in 15% liver metastases developed. The median survival time of the CAI (celiac artery infusion)-treated patient group compared favorably to the median survival of 9.3 months in a matched historical control group, being significantly longer (p < 0.0003). CONCLUSION: Adjuvant celiac artery infusion seemed to prolong median survival and the occurrence of liver metastases appeared to be delayed or reduced.

The generation of oxygen radicals after drinking of oxygenated water.

UNLABELLED: It has been speculated whether ingestion of oxygenated water can lead to an enhanced generation of oxygen radicals. The purpose of three prospective randomized blinded clinical studies was therefore to measure if, when and at which oxygen content in the water,drinking of oxygenated water induces the generation of radicals. Moreover in the fourth prospective,randomized, blinded study possible longterm effects of drinking oxygenated water were examined. METHODS: Altogether 66 volunteers were drinking 300 ml oxygenated or tap water within 15 minutes. Before drinking, altogether 15 ml of blood from the antecubital vein was collected for determination of ascorbyl radicals with ESR, routine laboratory data (hemoglobin, erythrocytes, hematocrit, leukocytes, thrombocytes, uric acid) and the vitamins A,C,E by HPLC. After drinking the ascorbyl radical measurements were repeated from blood of the antecubital vein. In the longterm study ( fourth study) the volunteers had to undergo the same procedure, as described above, at day 1 and day 21. In the meantime they were drinking per day three times 300 ml either oxygenated water or tap water. RESULTS: All subjects exhibited normal vitamin levels in all three studies. Concommitantly in the fourth study there was no statistically relevant alteration of vitamin concentrations during the observation period of three weeks in the verum and placebo-group. 30 minutes after drinking oxygenated water the concentration of ascorbyl radicals increased significantly by median 42 % from median 48 to 65 nmol/l. This increase of ascorbyl radicals after 30 minutes was reproducible in all studies. The levels of ascorbyl radicals remained elevated for 60 minutes after drinking and returned to normal after 120 minutes. This increase was independent of the oxygen concentration in the water, beginning at 30 mg oxygen/l. Water containing 15 mg oxygen/l did not lead to an enhanced radical formation. Longterm consumption of oxygenated water attenuated the ascorbyl radical increase normally observed, thus the initial increase of ascorbyl radicals at day 1 could not be observed after day 21, if the subjects were drinking oxygenated water regularly during the observation period. CONCLUSION: Drinking of oxygenated water possibly leads to a time-limited, yet very moderate, systemic generation of radicals. Regular consumption of oxygenated water over a longer period of time seems to attenuate this effect. The mechanisms leading to this effect and adaptation are unknown.

Surgical therapy for peptic ulcer and nonvariceal bleeding.

Wider use of endoscopic hemostasis in upper gastrointestinal bleeding (UGIB) has reduced significantly the need for operation. Nevertheless, surgery still plays a pivotal role. Failure to control bleeding endoscopically should not delay surgery when necessary, and a close cooperation between endoscopists and surgeons is essential. Initial endoscopy stops the bleeding in approximately 94% of patients and helps to identify those patients with a high or low risk of rebleeding. High-risk patients should be examined for rebleeding by clinical and endoscopic assessment within at least the first 2-3 days. Large ulcers are the most likely to rebleed, and in elderly patients with severe comorbidity showing little or no healing tendency, they benefit from repeated fibrin glue treatment. In cases of rebleeding despite initial endoscopic hemostasis and conservative treatment, another attempt to stop the hemorrhage endoscopically is justified in most patients. A subgroup of patients who are old, suffering from hypotension due to rebleeding, with large ulcers and several other illnesses should undergo surgery immediately because endoscopic intervention often fails, and these patients deteriorate quickly. The surgical procedure should be limited to safe hemostasis.

[Superior mesenteric vein syndrome: a case of duodenal stenosis caused by atypical malposition of the superior mesenteric vein]. / Vena-mesenterica-superior-Syndrom--eine Duodenalstenose, bedingt durch eine atypisch verlaufende V. mesenterica superior.

Cases in which mesenteric vessels lead to stenosis of the duodenum are very rare. Several cases have been reported of patients suffering from stenosis of the last third of the duodenum due to a malpositioning of the superior mesenteric artery or the left renal vein. We report a 78-year-old patient who was suffering from dyspepsia, pain in the upper abdominal region, nausea, and vomiting. The medical history revealed that the patient had undergone a subtotal gastrectomy according to Billroth II at the age of 19 because of similar complaints. In the last 20 years the patient had to be laparotomized several times for ileus of the small intestine. Now the patient presented abdominal complaints with nausea and pressure in the upper abdominal region. Assuming an efferent-loop syndrome and adhesions, the patient was laparotomized. We discovered malpositioning of the superior mesenteric vein, leading to stenosis of the superior part of the duodenum. In fact, 60 years ago surgeons performed a duodenojejunostomy, circumvening the stenosis of the duodenum. With a "delay of 60 years", we then performed a subtotal gastrectomy according to Billroth II. The postoperative course was uneventful; the patient had no complaints and increased in body weight. To our knowledge, this is the first time that a stenosis of the duodenum due to malpositioning of the superior mesenteric vein has been observed.

[Benign tumors of the Vater's papilla]. / Gutartige Tumore der Papilla Vateri.

BACKGROUND AND OBJECTIVE: Villous adenoma is the most common tumour of the papilla of Vater, and transition from adenoma to carcinoma is now generally accepted as proven. It is thus essential for an adenoma to be removed. Methods of removal have ranged from endoscopic sling papillectomy to partial duodenopancreatectomy. It was the aim of this study to determine whether recurrence can be prevented by local resection. PATIENTS AND METHODS: 58 patients with a benign tumour of the papilla (26 men, 32 women; average age 59 [range from 18 to 81] years) were included. Depending on preoperative histology, intraoperative frozen-section diagnosis and macroscopic histopathology, some form of surgical intervention was undertaken, most often resection of the ampulla. The clinical course and findings at postoperative follow-up were recorded and the absence of recurrence checked by endoscopy. RESULTS: Ampullectomy was performed in 49 of the 58 patients, papillectomy in three. Although frozen-section examination had failed to reveal any malignancy, resection of the head of the pancreas with preservation of the pylorus was done in six patients, carcinoma having been suspected macroscopically. There were no operative deaths. An adenoma had been found in 44 patients, one quarter of them showing severe dysplasia: follow-up examinations after a mean interval of 45 months (range of 6-180 months) failed to find any recurrence. CONCLUSION: Ampullectomy provides an adequate surgical treatment of benign adenoma of the ampulla of Vater. Accurate surgical technique and pre-, intra- and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. If the histological findings as to benignity are unclear, resection of the head of the pancreas with preservation of the pylorus by an experienced surgeon is indicated.

[Stage-adapted reconstruction of the stomach after gastrectomy]. / Stadiengerechte Ersatzmagenrekonstruktion nach Gastrektomie.

The only realistic chance of a cure for cancer of the stomach is gastrectomy with a wide margin of clearance. The question as to what constitutes the ideal reconstruction of a substitute stomach, however, remains unanswered. A number of prospective randomized studies show that patients operated on in curative intent and with a good long-term prognosis, should be given a substitute stomach in the form of a pouch constructed from small bowel, with restoration of duodenal passage. On account of the shorter operating time, patients receiving palliative surgery should be treated with a simple oesophagojejunostomy without such a small-bowel pouch substitute stomach.

Pathophysiologic role of oxygen free radicals in acute pancreatitis: initiating event or mediator of tissue damage?

BACKGROUND AND OBJECTIVE: Oxidative stress is an important factor in the pathogenesis of acute pancreatitis, as shown in vivo by the beneficial effects of scavenger treatment and in vitro by the potential of free radicals to induce acinar cell damage. However, it is still unclear whether oxygen free radicals (OFR) act only as mediators of tissue damage or represent the initiating event in acute pancreatitis in vivo as well. In the present study the authors aimed to address this issue in an experimental set-up. MATERIALS AND METHODS: Two hundred male Wistar rats were randomly assigned to one of the following experimental groups. In two groups, acute necrotizing pancreatitis was induced by retrograde intraductal infusion of 3% sodium taurocholate. Through the abdominal aorta, a catheter was advanced to the origin of the celiac artery for continuous regional arterial (CRA) pretreatment with isotonic saline (NP-S group) or superoxide dismutase/catalase (NP-SOD/CAT group). In another group, oxidative stress was generated by CRA administration of xanthine oxidase and intravenous administration of hypoxanthine (HX/XOD group). Sham-operated rats received isotonic saline both arterially and intraductally. After observation periods of 5 and 30 minutes and 3 and 6 hours, the pancreas was removed for light microscopy and determination of reduced glutathione (GSH), oxidized glutathione (GSSG), conjugated dienes (CD), and malondialdehyde as a marker for OFR-induced lipid peroxidation as well as myeloperoxidase as a parameter for polymorphonuclear leukocyte accumulation. RESULTS: A significant decrease of GSH was paralleled by an increased ratio of GSSG per total glutathione and elevated CD levels after 5 minutes in the NP-S group versus the sham-operated group. Thereafter, the percentage of GSSG and GSH returned to normal levels until the 6-hour time point. After a temporary decrease after 30 minutes, CD levels increased again at 3 hours and were significantly higher at 6 hours in contrast to sham-operated rats. Myeloperoxidase levels were significantly elevated at 3 and 6 hours after pancreatitis induction. In contrast to NP-S rats, treatment with SOD/CAT significantly attenuated the changes in glutathione metabolism within the first 30 minutes and the increase of CDs after 6 hours. HX/XOD administration lead to changes in levels of GSH, GSSG, and CDs at 5 minutes as well as to increased myeloperoxidase levels at 3 hours; these changes were similar to those observed in NP-S rats. Acinar cell damage including necrosis was present after 5 minutes in both NP groups, but did not develop in HX/XOD rats. In addition, serum amylase and lipase levels did not increase in the latter group. SOD/CAT treatment significantly attenuated acinar cell damage and inflammatory infiltrate compared with NP-S animals during the later time intervals. CONCLUSION: OFRs are important mediators of tissue damage. However, extracellular OFR generation alone does not induce the typical enzymatic and morphologic changes of acute pancreatitis. Factors other than OFRs must be involved for triggering acute pancreatitis in vivo.

Mechanism and role of trypsinogen activation in acute pancreatitis.

In healthy subjects, the 3 known pancreatic trypsinogens, which are endopeptidases belonging to the chymotrypsin superfamily, are activated by enterokinase and partial autoactivation in the duodenum. The premature activation of trypsinogen in the pancreatic interstitium, with the subsequent activation of other pancreatic zymogens, is believed to lead to the autodigestion of the gland, this being the first event in acute pancreatitis. The mechanisms that lead to trypsinogen, activation in acute pancreatitis are largely unknown. However, ischemia, hypercalcemia and the activation of cathepsin B (by cholecystokinin) are thought to be of importance. The easiest and most reliable way to assess trypsinogen activation is the measurement of the activation peptide, TAP, in urine, plasma, pancreatic tissue or ascitic fluid. In the animal model of acute pancreatitis, TAP in ascites and pancreatic tissue has been shown to correlate with the presence and extent of necroses. It has proven to be a good marker for the severity of pancreatitis and is a useful marker in examining the pathophysiology and possible treatment modalities in the animal model of acute pancreatitis. Studies on TAP in human acute pancreatitis were most commonly focused on urinary TAP. Within a 48-hour time frame after the onset of the disease, TAP was a good predictor of the severity of acute pancreatitis. The main advantage over other markers, such as CRP, is that TAP is the earliest marker of necrosis to be increased. Also, increased levels of TAP in ascitic fluid were shown to correlate well with pancreatic necroses. In our experience, plasma TAP was found to have a "diagnostic window" within the first 3 days predicting pancreatic necroses. Positive TAP gave a very good positive prediction and a high specificity towards the development of pancreatic necroses, but did not differ between necrotizing pancreatitis with systemic complications or uncomplicated necrotizing pancreatitis. We therefore think that plasma TAP is a very good marker for local complication in acute pancreatitis and its routine measurements may help to identify patients at a high risk within the first days of the disease.

[Pouch stomach reconstruction after gastrectomy]. / Ersatzmagenrekonstruktionen nach Gastrektomie.

Up to now there is no general agreement on the ideal reconstruction after total gastrectomy. The importance of the duodenal passage, the need for a pouch reconstruction, and the ideal pouch volume are matters of controversy. Prospective randomized trials show a significantly better quality of life, a higher body weight and a better glucose regulation in patients with a curative operation and good life expectancy, if the duodenal passage is preserved. Reconstruction with a small jejunal pouch offers a better reservoir, less reflux and a better nutritional passage, but a statistically significant improvement of life quality could not be demonstrated up to now. Nevertheless, patients with a curative resection should undergo pouch reconstruction with preservation of the duodenal passage. If curative resection is not possible, reconstruction can be performed according to Hunt-Lawrence-Rodino. The Roux-en-Y-reconstruction without pouch should only be performed in high-risk patients and in carcinoma of the cardia with intrathoracic anastomosis. Nevertheless, further prospective randomized studies with more patients and more specific tests to measure life quality are necessary to evaluate the importance of a jejunal pouch in patients with a preserved duodenal passage.

[Is a Whipple operation in chronic pancreatitis still a current procedure?]. / Ist die Whipplesche Operation bei chronischer Pankreatitis noch zeitgemäss?

Until the eighties, the surgical procedure of choice in chronic pancreatitis with an inflammatory mass in the head of the pancreas has been partial duodenopancreatectomy (pDP). Since neither stomach, duodenum nor the common bile duct are directly involved in the inflammatory process of the pancreas, the Whipple's procedure (pDP) might lead to overtreatment. Therefore, duodenum-preserving pancreatic head resection (DPPHR), developed by Beger in 1972, has become in several centers the standard procedure for patients with an inflammatory enlargement of the head of the pancreas. We reviewed the literature of the last ten years and evaluated the different surgical procedures for pancreatic head resection. Comparing pDP and DPPHR. Whipple procedure has a higher hospital mortality (3.2% versus 0.6%), a higher late mortality (22% versus 8.4%), a higher morbidity and a higher incidence of a new "surgical" diabetes (17.6% versus 2%). With regard to relief of pain long-term investigations show totally pain-free patients after pDP in 72%, after pylorus-preserving duodenopancreatectomy (PPDP) in 82% and after DPPHR in 89%. Furthermore, other disadvantages of PPDP are the high rate of gastric outlet dysfunction (17% on average with a range of 4-32%) and the high rate of marginal ulcers (8.4% on average with a range of 5-11%). In summary, we conclude that in patients with chronic pancreatitis and an inflammatory enlargement of the pancreatic head. DPPHR is the procedure of choice. Whipple's procedure should only be performed if a suspicion of malignancy is suspected or, secondly, if a patient suffers from persistent pain (5%) after DPPHR.

Distal pancreatectomy in chronic pancreatitis.

BACKGROUND: The indications for a resective procedure in chronic pancreatitis are severe pain and local complications. The aim of this study, based on prospectively assessed data, was to evaluate distal pancreatectomy in patients suffering from chronic pancreatitis localized in the corpus and cauda of the pancreatic gland. METHODS: Seventy-four patients undergoing distal pancreatectomy were evaluated pre- and postoperatively (after a median observation period of 58 months) for pain, professional status, alcohol consumption, and endocrine function as measured by the glucose tolerance test preoperatively. RESULTS: The indication for operation was severe therapy-resistant pain in nearly all patients and an inflammatory tumor or pancreatic pseudocysts in over 50% of the patients. One fourth of the patients were operated in order to exclude malignancy. Ninety-five percent of the patients underwent distal pancreatectomy, only in 4 cases (5%) was a subtotal (Child) resective procedure performed. In 34% of patients undergoing distal pancreatectomy a splenectomy could be avoided. The early postoperative complications were few and mostly due to the severe comorbidity of the patients. During the median observation period of 58 months 14.7% of the patients died due to diseases not related to distal pancreatectomy. Six percent of the patients could not be reevaluated and were lost to follow-up. In the remaining 59 patients 88% had significantly less pain and 66% had an increase in median body weight of 8 kg. Fifty percent of the patients had full or partial professional rehabilitation, one fourth was unemployed and 24% had retired due to age. 51.7% had a normal endocrine function as assessed by the glucose tolerance test, 16.2 and 21.6% had a latent or manifest diabetes mellitus, respectively. In 74.5% of all patients the endocrine function did not worsen during the observation period. CONCLUSION: In comparison to conservative treatment distal pancreatectomy is a suitable therapeutic measure in patients with severe pain and local complications. It significantly improves the quality of life of patients without compromising endocrine function. Postoperative lethality is lower than in conservatively treated patients and is not related to distal pancreatectomy.

New approaches in surgical management of severe acute pancreatitis.

Despite many prospective randomized clinical studies a specific pharmacotherapy for severe acute pancreatitis is not in sight. To date, the only possibility to influence the prognosis of this severe illness is early diagnosis and prevention of intra- and extrapancreatic necrosis and its subsequent infection. In severe necrotizing pancreatitis the incidence of infected necrosis amounts to 40-70% of all patients within 3 weeks. Thereby, the clinical picture often varies to large extent. Ultrasonographically or computer tomography-guided fine-needle aspiration (FNAC) is a fast and reliable technique for diagnosis with an overall sensitivity of 88% and specificity of 90%. This method should however not be applied too early in the course of necrotizing pancreatitis. Since infection of pancreatic necrosis determines significantly the prognosis of disease, various studies have assessed the efficacy of prophylactic antibiotic treatment in patients. Three prospective randomized studies have shown that prophylaxis significantly minimizes septic complications, only in one study, however, the mortality rate could be improved. Although randomized studies are still mandatory to resolve the controversy, it seems justified to recommend prophylaxis with antibiotics which are capable of penetrating the pancreatic tissue and juice. Sterile necrosis should be treated conservatively, with prophylactic antibiotic treatment for as long as possible. Only if patients worsen despite intensive care medicine, surgical debridement should be considered. In contrast, in patients with infected necrosis immediate surgery is in most cases mandatory. Although in one prospective study conservative treatment did not lead to an enhanced mortality rate, possible delay of surgical treatment may endanger the patient. In order to improve the prognosis of the disease, timely and adequate treatment in specialized units provides the best chances for a good prognosis whereby the severely ill patient should not be treated according to a scheme but to his/her individual needs.

Clinical course after total parathyroidectomy without autotransplantation in patients with end-stage renal failure.

In patients with chronic renal failure, hyperparathyroidism is a common problem and surgical parathyroidectomy (PTX) is frequently required. The three different surgical approaches are subtotal PTX, total PTX with autotransplantation, and total PTX without autotransplantation. Recurrence of hyperparathyroidism varies from 5% to 80% in different studies for the first two surgical approaches. To minimize the risk for recurrence, and because we fear severe relapses with calciphylaxia, we perform total PTX without autotransplantation. From October 1993 to October 1997, 20 patients (9 men and 11 women) underwent total PTX without autotransplantation (median age, 52 years; range, 23 to 74 years; median dialysis time before PTX, 6.5 years; range, 1 to 22 years). All patients were supplemented with vitamin D analogues postoperatively. Patients were followed up for 1 to 48 months (median, 20 months). Bone pain, when present, disappeared within the first week after total PTX. Postoperatively, most patients had temporary hypocalcemia. In the long term, five patients had asymptomatic hypocalcemia. One patient, however, repeatedly had hypocalcemic seizures. Five patients developed asymptomatic hypercalcemia when supplemented with calcitriol. At the end of the individual's observation time, parathyroid hormone (PTH) levels were less than normal in six patients, normal in seven patients, and increased in seven patients despite total PTX. We conclude that total PTX should be reconsidered an option for the treatment of hyperparathyroidism secondary to renal failure. There was no evidence of clinical bone disease after total PTX. Apparently, remaining ectopic parathyroid tissue accounts for PTH levels after total PTX.

Benign tumour of the ampulla of Vater: surgical treatment and prognosis.

OBJECTIVE: To find out whether wide local resection is adequate treatment for patients with benign tumours of the papilla of Vater. DESIGN: Retrospective study. SETTING: University hospital, Germany. SUBJECTS: 31 patients with benign tumours out of a total of 129 with lesions of the ampulla of Vater treated between May 1978 and February 1995. INTERVENTIONS: Histological examination of specimens before, during, and after the operation. MAIN OUTCOME MEASURES: Sensitivity and positive predictive value of histological examination, and outcome of treatment. RESULTS: Histological examination before and during the operation had a sensitivity of 89% and 97%, respectively. 28 patients were treated by wide excision of the ampulla and 3 by pylorus-preserving partial pancreaticoduodenectomy. At a median follow up of 43 months (range 6-156) there was no evidence of recurrent disease. CONCLUSION: Wide excision of the ampulla with reconstruction and reimplantation of the duct is adequate treatment for benign lesions. If the histological picture is uncertain, partial pancreaticoduodenectomy is justified in patients at low risk.