Metastasis to the pancreas--an indication for pancreatic resection?

BACKGROUND AND AIMS: Isolated metastatic involvement of the pancreas is very rare. To evaluate the possible benefit of surgery, we retrospectively analyzed patients that underwent pancreatic resection for metastases into the pancreas. PATIENTS/METHODS: In 12 patients (8 men and 4 women), metastatic disease was treated by pancreatic resection (two total pancreatectomies, nine pylorus-sparing duodenopancreatectomies, and one left-side pancreatic resection) between 1993 and 2005 at our institution. Primary malignomas were renal cell carcinoma (RCC; n = 7), malignant melanoma (n = 4), and colon cancer (n = 1). All patients were followed-up until November 2006 or until death. RESULTS: Complications requiring relaparotomy were found in two patients (retroperitoneal abscess and bile fistula), whereas one patient with pancreatic fistula could be treated by conservative measures. There was no perioperative mortality. Median survival time was 51 months (5-105 months). At the end of follow-up, seven patients were alive at 12 to 86 months, whereas five died between 5 and 105 months: four died of the disease, and one patient died of cardiac failure without evidence of recurrent cancer. CONCLUSION: Patients with isolated pancreatic metastasis particularly of RCC benefit from surgery. Pancreatic resection may achieve long-term survival or good palliation in selected cases of other primaries as well.

Duodenal somatostatinoma: clinical and immunohistochemical patterns--difficult differential diagnosis in regard to gangliocytic paraganglioma: report of a case.

The authors report a large duodenal somatostatinoma, a very rare tumor entity. A 8.5 cm globular mass in the area of the unicate process of the pancreas was detected in a 45 year old caucasian female by computerized tomography. The patient had only mild complaints. Initial treatment consisted of right pancreatectomy with preservation of the pylorus. Histological evaluation rendered a diagnosis of low-grade malignant neuroendocrine carcinoma with expression of somatostatin, respectively of somatostatinoma arising in the duodenum and infiltrating into the pancreas. 26 months after the initial surgery liver and lymph node metastases were detected and surgically removed. This case confirms that duodenal somatostatinomas are very difficult to diagnose preoperatively because of unspecific symptoms. Most duodenal somatostatinomas are found incidentally. Treatment of choice is radical surgical resection with a possible cure in early stages of the disease. Even a large tumor as ours is resectable with negative surgical margins. Management of recurrent or metastatic disease is also surgical. Additional chemotherapy and supportive care may be beneficial for the patient.

[Surgical palliation of pancreatic carcinoma. Results of a 7 year period]. / Chirurgische Palliation beim Pankreascarcinom. Ergebnisse aus einem 7-Jahresintervall.

INTRODUCTION: High perioperative complication rates in the 1980s led to preferred use of endoscopic therapy for surgical palliation of pancreatic cancer. This encouraged us to analyse our own patients retrospectively. MATERIAL AND METHODS: In the period from 1 January 1992 to 31 December 1998, 253 patients with an exocrine carcinoma of the pancreas were operated on at the St. Elisabeth Hospital Cologne-Hohenlind: 73 patients (28.9%) underwent curative resection (R0) while 180 patients (71.1%) had palliative operative treatment (R1/R2). Palliative resection was performed in 22 patients (8.7%). Intestinal bypass surgery was done in 113 patients (44.7%) as a gastrojejunostomy and in 16 patients (6.3%) as a duodenojejunostomy. A biliodigestive anastomosis was performed in 85 patients (33.6%). This procedure was combined with a gastroenterostomy in 78 patients (30.8%). In 18 patients (7.1%) no surgical palliation was possible and the operation finished as a diagnostic laparotomy. RESULTS: The overall mortality rate within the first 30 (60) days was 5.5% (12.7%). Patients whose carcinoma had been resected curatively had a 30 (60)-day mortality rate of 2.7% (4.1%), compared to a rate in palliatively treated patients (resection/bypass/probatoria) of 6.7% (16.1%). Patients with palliatively resected tumor had perioperative mortality of 4.5% (4.5%), whereas patients who did not undergo resection had 6.9% (17.7%). The survival rate for curatively resected patients after Kaplan-Meier extrapolation was 64.7% after 1 year and 31.2% and 26.2% after 3 and 5 years, with a median survival time of 552 days. Palliatively operated patients had a survival rate of 19.4%, 2.5% and 0% for 1, 3 and 5 years. Median survival time was 171 days in this situation. Compared to patients without resection (17.4% and 2.0%), patients with palliative resection had survival rates for 1 and 3 years of 40% und 5.9%. After 5 years none of these patients were alive. CONCLUSIONS: Our data show a high success of surgical palliation in pancreatic cancer in centers with a high frequency of pancreatic surgery. Patients that could not be cured (R1/R2), although undergoing extensive procedures, had better survival rates than patients treated with bypass surgery. Perioperative mortality rate was comparatively low. This justifies aggressive surgical management of pancreatic carcinoma.

Two cases of colorectal cancer complicating Crohn's disease and review of the literature.

Two cases of colorectal carcinoma complicating Crohn's disease are reported and the relevant literature is reviewed. It is important to be aware of this increasing complication and the specific group of patients at risk. Special attention to possible malignant transformation could lead to earlier diagnosis and treatment.

[Possibilities of surgical and drug therapy of parasitic cholestasis]. / Möglichkeiten chirurgischer und medikamentöser Therapie bei parasitärer Cholostase.

Out of 123 patients with hydatid-disease of the liver in 15 patients biliary engorgement by compression from cysts or parasites in the biliary system were observed. Diagnosis can be established by serology, sonography, scintigraphy, ERCP and CT. Invasive diagnostic procedures are not indicated. Surgical therapy of echinococcosis is in the first place; long-term adjuvant chemotherapy by Mebendazole is indicated if the resection of the cysts is not complete.

[B II-Y-Roux anastomosis--resection procedure of choice in complicated ulcer?]. / B II-Y-Roux-Anastomose--Resektionsverfahren der Wahl bei der komplizierten Ulcuskrankheit?

43 patients with complicated gastric, duodenal or anastomotic ulcers resected according to Billroth II-Roux were controlled clinically, by endoscopy and X-ray. Little amounts of bile acid were found in only one case. Two groups with different pH-values were verified: 6 patients with pH from 1.2 to 2.2; three of them had recurrent ulcers. In the other group of the remaining 37 patients pH was higher than 5.5; there was only one recurrence in a patient with HPT. According to the Visick grading system results were good or excellent in 86%. The study shows that under conditions of no bile reflux and maintained vagal stimulation recurrence of ulcer is probable. In the acid ulcer type (Johnson II and III), duodenal ulcer and anastomotic ulcer supplementary vagotomy is recommendable.

[Stress-induced haemorrhages in intensive care patients (author's transl)]. / Stressblutungen bei Intensivpatienten.

An analysis of the case material of the intensive care unit of the Department of Surgery showed haemorrhages from acute gastro-duodenal lesions in 8% of the cases. Control of the bleeding by therapeutic lavage with suspensions of antacids was the more effective the higher the frequency of application. Prophylactic lavage with antiacids in patients liable to develop gastric bleeding succeeded in reducing the incidence of this complication to 1%. Prophylactic administration of Cimetidine had the same effect.

[Binding capacity of sex hormone binding globulin and corticosteroid binding globulin in serum of male patients with liver cirrhosis (author's transl)]. / Bindungskapazität von sexualhormon- und corticosteroidbindendem Globulin im Serum bei Männern mit Lebercirrhose.

The binding capacities of SHBG and CBG were measured by agar gel electrophoresis in 63 men with cirrhosis of the liver and in 42 healthy male subjects. The normal range (X- +/- 2s) for SHBG was 8.3-17.1 microgram/l, for CBG 46.4-82.8 micrograms/l. SHBG binding capacity was significantly higher in men with liver cirrhosis (mean 18;1 microgram/l; p less than 0.001) but CBG binding capacity was significantly lower (mean 49.7 microgram/l; p less than 0.001). Although SHBG was lower in patients with decreased CBG binding capacity, a correlation between both steroid binding proteins did not exist. Moreover, there was no correlation between SHBG or CBG on one hand and other parameters of hepatic protein synthesis such as serum protein concentration, cholinesterase activity and the coagulation factors V and VII on the other hand. In contrast to liver cirrhosis, 12 patients with fatty liver and 11 patients with toxic fibrosis of the liver did not reveal changes in SHBG or CBG. Treatment with spironolactone (200 mg daily for one week in 9 subjects) did not change the steroid binding capacity of human serum.

[Endoscopic transpapillary splitting of a choledochocele (author's transl)]. / Endoskopische transpapilläre Spaltung einer Choledochocele.

A choledochocele with obstruction to outflow from the biliary and pancreatic duct systems was diagnosed by endoscopic retrograde cholangio-pancreatography in a 67-year-old man with radiating upper-abdominal pain and constantly elevated gamma-glutamyl transferase. After distension of the choledochocele with contrast medium a papillotome was introduced across the papilla and the choledochocele was split open. There were no complications and flow from both systems became normal. The symptoms disappeared and the patient required neither anaesthesia nor an abdominal operation.

[Lens induced myopia in steroid cataracts (author's transl)]. / Linsenmyopie bei der Steroidkatarakt.

Longterm investigations of patients on immun-suppressive corticosteroid therapy showed that the development of advanced corticosteroid cataracts is accompanied by a marked increase of lens myopia up to 7.5 dpt. It can be assumed that this phenomenon is due to the optical effect of the discoid posterior subcapsular opacities.

[Surgical management of liver trauma (author's transl)]. / Zur Problematik der Leberverletzung.

Surgical management and follow up of 85 patients with liver trauma are reported. 20 patients had only liver trauma, all others were polytraumatised. Letality was 20% in patients with sole liver trauma, the overall letality was 43%. In most cases death resulted from prolonged circulatory shock. Most of the other casualities resulted from septical complications of biliary peritonitis. Prognosis was mainly correlated with the interval between trauma and surgical treatment as well as with the amount of blood lost. The main features of the operative technic were access to the liver through a subcostal and sometimes transdiaphragmal incision, temporary tamponade of the bleeding source, compression of the hepatoduodenal ligament, of the vena cava (intrapericardial) to minimize blood loss. Instead of hemihepatectomy, resection of liver tissue was limited to the smallest amount possible, and followed by extensive drainage.

[Radiological lung changes after thoracoabdominal surgery in the lateral decubitus position (author's transl)]. / Röntgenologische Lungenveränderungen nach thorakoabdominalen Eingriffen in Seitenlage

Radiological changes that may occur in the depenent lung when surgery is performed in the lateral position are generally of a transient nature; they disappear when the position of the patient is changed after the operation, but may, in some cases, be demonstrable post-operatively as atelectatic areas. From the second post-operative day onwards, and reaching a peak on the 5th post-operative day, there is an increased incidence of ventilatory disturbances and infiltrations. The course and distribution of these pulmonary disturbances point to post-operative immobilization in the recumbent position as the main causal factor.

[Cataract during intermittent hemodialysis. The influence of hypocalcemia on the development of opacities (author's transl)]. / Katarakt bei intermittierender Hämodialyse. Uber die Bedeutung einer Hypokalzämie für die Trübungsentwicklung

Twenty uremic patients on intermittent hemodialysis were followed up for lens changes over 4-53 months. Only one patient of 22 years with megaureters and megacystis developed bilateral anterior and posterior subcapsular cataracts during dialysis treatment. The morphology of these cataracts was similar to that of fresh hypocalcemic opacities. The patient had actually been hypocalcemic before the onset of the opacification. Possible reasons for the development of hypocalcemic cataracts during intermittent dialysis might be: 1. a reduced calcium-phosphate ratio due to phosphate accumulation, 2. a decrease of ionized calcium due to removed metabolic acidosis, and 3. a permissive effect of longer latencies.

[Psychopathological findings and social psychiatry problems in patients with transplanted kidneys]. / Psychopathologische Auffälligkeiten und Sozialpsychiatrische Probleme bei nierentransplantierten Patienten

Chronic haemodialysis and kidney transplantation reveal a great number of psychological and psychiatrical problems and tasks. As there are special psychological problems and many psychoreactive symptoms and the fact that haemodialysis and kidney transplantation are strain situation in themselves, one should examine the question of capability, and often a psychiatric or psychotherapeutic treatment is necessary. Authors examined twelve patients who had undergone kidney transplantation, regarding their psychopathological and social-psychiatrical status. The great improvement in the quality of life in comparison to the time of dialysis treatment is often reduced, however, because of psychological and severe social problems as well as deficient or missing steps of rehabilitation.

[Corticosteroid cataracts following kidney transplantation. Investigations on the influence of additional factors upon the development of opacities (author's transl)]. / Kortikosteroidkatarakte nach Nierentransplantation. Untersuchungen über den Einfluss von Zusatzfaktoren auf die Trübungsentwicklung

15 patients with kidney transplants were followed up for a period of 3 to 45 months. All but one developed lenticular opacities in the posterior subsapsular region. The opacities were classified according to their severity. It could be shown that the cataract index was correlated to the total amount of corticosteroids given. There is probably an additional effect of age and azathioprin therapy. Possibly, the time of treatment with intermittent hemodialysis also influences cataract development.