Pancreatic resections for advanced M1-pancreatic carcinoma: the value of synchronous metastasectomy.

BACKGROUND: For M1 pancreatic adenocarcinomas pancreatic resection is usually not indicated. However, in highly selected patients synchronous metastasectomy may be appropriate together with pancreatic resection when operative morbidity is low. MATERIALS AND METHODS: From January 1, 2004 to December, 2007 a total of 20 patients with pancreatic malignancies were retrospectively evaluated who underwent pancreatic surgery with synchronous resection of hepatic, adjacent organ, or peritoneal metastases for proven UICC stage IV periampullary cancer of the pancreas. Perioperative as well as clinicopathological parameters were evaluated. RESULTS: There were 20 patients (9 men, 11 women; mean age 58 years) identified. The primary tumor was located in the pancreatic head (n = 9, 45%), in pancreatic tail (n = 9, 45%), and in the papilla Vateri (n = 2, 10%). Metastases were located in the liver (n = 14, 70%), peritoneum (n = 5, 25%), and omentum majus (n = 2, 10%). Lymphnode metastases were present in 16 patients (80%). All patients received resection of their tumors together with metastasectomy. Pylorus preserving duodenopancreatectomy was performed in 8 patients, distal pancreatectomy in 8, duodenopancreatectomy in 2, and total pancreatectomy in 2. Morbidity was 45% and there was no perioperative mortality. Median postoperative survival was 10.7 months (2.6-37.7 months) which was not significantly different from a matched-pair group of patients who underwent pancreatic resection for UICC adenocarcinoma of the pancreas (median survival 15.6 months; P = .1). CONCLUSION: Pancreatic resection for M1 periampullary cancer of the pancreas can be performed safely in well-selected patients. However, indication for surgery has to be made on an individual basis.

[Spontaneous rupture and embolization: a rare complication of port catheter implantation]. / Spontane Ruptur und Embolisation: Eine seltene Komplikation nach Port-Katheter-Implantation.

HISTORY AND CLINICAL FINDINGS: A 70-year-old male patient had a venous port catheter implanted into his right subclavian vein for neoadjuvant radio-chemotherapy of a rectal carcinoma (T3N0N0). Due to the patient's difficult venous access the catheter was left in situ after treatment. 31 weeks later he was admitted to the hospital because of parasternal and subclavicular pain. INVESTIGATIONS: Physical examination and an electrocardiogram revealed no abnormalities. A chest x-ray was performed. DIAGNOSIS, TREATMENT AND COURSE: The chest x-ray showed a normal location of the port-system but the tip of the catheter had embolized into the right atrium. The embolized fragment was extracted with a loop-snare technique and the reservoir of the system was removed under local anaesthesia without any complications. CONCLUSIONS: Despite its frequent use intravascular embolization of catheter fragments from implantable venous port-catheter systems present a rare but potentially life-threatening complication. Any implanted catheters should therefore be removed after completion of treatment or the system's integrity should be monitored on a regular basis.

Treatment of achalasia: recent advances in surgery.

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Endo-organ and laparoscopic management of gastric leiomyomas.

Various techniques have been reported for the laparoscopic treatment of benign gastric lesions, depending on the site of the lesion. Recently, a new technique of endo-organ gastric surgery has been developed that is particular useful for the treatment of lesions on the posterior gastric wall. We report on two patients with submucosal gastric tumors. A 79-year-old man was found to have a submucosal tumor near the esophagogastric junction in the posterior wall of the stomach. Endosonography suggested that the tumor was a gastric leiomyoma. Under endoscopic guidance, three ports were inserted into the stomach and the tumor could be successfully enucleated. A 78-year-old woman was found to have a 2 x 1-cm submucosal tumor at the anterior wall of the antrum. The tumor was successfully removed by laparoscopic gastrotomy and resection. The various laparoscopic techniques for the treatment of gastric lesions are discussed.