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.

[Video-assisted transanal endoscopic microsurgery of rectal tumours - V-TEM]. / Videoassistierte transanale endoskopische Mikrochirurgie von Rektumtumoren - V-TEM.

BACKGROUND: Transanal endoscopic microsurgery (TEM) has become increasingly established as the method of choice for the local resection of endoscopically unresectable rectal adenomas and early-stage, low-risk rectal carcinomas. Multiple studies have shown that the single port-technique TEM results in significantly less trauma with comparable overall treatment outcome as compared to conventional radical surgical techniques. However, TEM is not widely used due to high initial set-up costs, the need for highly complex equipment and demanding surgical skill requirements. PATIENTS AND METHODS: To mitigate these challenges we have successfully developed a video-assisted TEM (V-TEM) method, which resulted in approximately 50 % lower initial set-up costs through the introduction of simplified original TEM surgical equipment. Between October 2003 and September 2011 we have completed 103 resections using the V-TEM method. RESULTS: The observed rates of complications and local recurrences are comparable to reported rates. CONCLUSIONS: We were able to mitigate the challenges of TEM through the establishment of the technically less demanding V-TEM method, which resulted in approximately 50 % lower initial set-up costs while maintaining overall treatment outcomes.

Pancreatic stellate cells promote hapto-migration of cancer cells through collagen I-mediated signalling pathway.

BACKGROUND: Pancreatic stellate cells (PSCs) promote metastasis as well as local growth of pancreatic cancer. However, the factors mediating the effect of PSCs on pancreatic cancer cells have not been clearly identified. METHODS: We used a modified Boyden chamber assay as an in vitro model to investigate the role of PSCs in migration of Panc1 and UlaPaCa cells and to identify the underlying mechanisms. RESULTS: PSC supernatant (PSC-SN) dose-dependently induced the trans-migration of Panc1 and UlaPaCa cells, mainly via haptokinesis and haptotaxis, respectively. In contrast to poly-L-lysine or fibronectin, collagen I resembled PSC-SN with respect to its effect on cancer cell behaviours, including polarised morphology, facilitated adhesion, accelerated motility and stimulated trans-migration. Blocking antibodies against integrin α2/ß1 subunits significantly attenuated PSC-SN- or collagen I-promoted cell trans-migration and adhesion. Moreover, both PSC-SN and collagen I induced the formation of F-actin and focal adhesions in cells, which was consistent with the constantly enhanced phosphorylation of focal adhesion kinase (FAK, Tyr397). Inhibition of FAK function by an inhibitor or small interference RNAs significantly diminished the effect of PSC-SN or collagen I on haptotaxis/haptokinesis of pancreatic cancer cells. CONCLUSION: Collagen I is the major mediator for PSC-SN-induced haptokinesis of Panc1 and haptotaxis of UlaPaCa by activating FAK signalling via binding to integrin α2ß1.

[Duodenum-preserving total pancreatic head resection : an organ-sparing operation technique for cystic neoplasms and non-invasive malignant tumors]. / Duodenumerhaltende totale Pankreaskopfresektion : Ein organsparendes Verfahren bei zystischen Neoplasien und nichtinvasiven malignen Tumoren.

Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.

[Indications for laparoscopic pancreas operations: results of a consensus conference and the previous laparoscopic pancreas register]. / Indikation zur laparoskopischen Pankreasoperation: Ergebnisse einer Konsensuskonferenz und des bisherigen laparoskopischen Pankreasregisters.

Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.

[GI hemorrhage with fulminant shock induced by jejunal gastrointestinal stromal tumor (GIST) coincident with duodenal neuroendocrine carcinoma (NET) + neurofibromatosis (NF) -- case report and review of the literature]. / Hämorrhagischer Schock bei Doppelmalignom: Gastrointestinaler Stromatumor (GIST) und neuroendokrines Karzinom bei Morbus Recklinghausen.

BACKGROUND: The incidence of neuroendocrine tumors (NET) and of gastrointestinal stromal tumors (GIST) is 0.5 and 1 - 2 in 100,000; the prevalence of neurofibromatosis is 1 in 3000 live births in Western countries. CASE REPORT: A 43-year-old white woman with a six-month history of meleana, paleness, vertigo and fatigue was not referred to any gastrointestinal doctor for diagnostic work-up. Finally, she collapsed and was admitted to hospital because of an acute gastrointestinal bleeding. Endoscopically the source of bleeding could not be localized while blood in the duodenum and proximal jejunum was demonstrable. The source of bleeding could not be identified by endoscopy, CT scan or angiography. The patient developed a fulminant gastrointestinal hemorrhage with hemoglobin levels below 3.5 g %. An emergency laparotomy and pylorus-preventing Whipple operation was performed. Pathological studies showed a GIST with 3.5 cm diameter of the proximal jejunum which was the source of bleeding. Coincidentally a neuroendocrine carcinoma of the duodenum was found. CONCLUSION: This case is the first presentation of the coincidence of a neuroendocrine carcinoma of the duodenum with a jejunal bleeding gastrointestinal stromal tumor in neurofibromatosis type1 which led to hemorrhagic shock. In neurofibromatosis -- even if non-symptomatic -- the increased incidence of tumor needs to be considered.

[A rare localization of annular pancreas at the pars horizontalis duodeni--case report]. / Seltene Lokalisation eines Pankreas anulare--Pars horizontalis duodeni--kasuistische Darstellung und chirurgische Therapie.

Annular pancreas is a rare congenital malformation of the pancreas. In about 50 % of the cases the malformation is asymptomatic until the second to fifth decade. We report on a 75-year-old male patient with an extremely rare localization of annular pancreas - namely at the pars horicontalis duodeni - who presented with recurrent vomiting and loss of weight. An end-to-side Roux-Y duodenojejunostomy was performed. After that procedure we discharged the patient on day eleven after surgery in good physical health condition. In a patient presenting signs of duodenal obstruction annular pancreas should be taken into account as a possibility.

[Cystic tumors of the pancreas-radical or organ-preserving resection?]. / Die Behandlung zystischer Tumoren des Pankreas. Radikal oder organsparend?

Cystic tumors comprise only 1% of all pancreatic tumors, although there is an increasing number of publications about them. These tumors divide into other tumor entities, some of them benign and some of them borderline or malignant. Therefore, the kind of therapy is presently under discussion. Between 1986 and 2003, we treated 97 patients with cystic tumors of the pancreas, evaluated the data retrospectively, and followed the patients up. Sixty-seven percent were treated by radical resection and 32% by organ-preserving resection. With 41%, postoperative "new" diabetes mellitus was significantly more frequent after radical resection than after organ-preserving resection at 24% ( P<0.01). Long-term survival was worst after mucinous cystadenocarcinoma (59% after 36 months), and 90% of all other patients lived longer than 36 months. We conclude that organ-preserving resection should be considered in all serous cystic tumors and solid pseudopapillary tumor of the pancreas. All mucinous cystic tumors are of malignant or borderline nature and should be treated as such by radical resection.

[Emergent surgery for body packing - what happens to the drugs?]. / "Bodypacker" als chirurgischer Notfall. Wem gehört das Rauschgift?

Body packing is a well recognized method of drug trafficking by smuggling drug containers in the gastrointestinal tract. Medical professionals might get involved with body packers after presentation by law enforcement or in case of medical emergencies such as drug overdose or mechanical intestinal obstruction due to the containers within the gastrointestinal tract. Besides the medical aspects in treating these patients, physicians must be aware of all the different legal specifics in dealing with body packers. In case of medical emergencies, drug traffickers have the legal status of regular patients with respect to professional medical discretion. The question remains of what physicians should do with the drugs after surgical removal? Even though the body packer remains the legal owner of the drugs, physicians may not return the drugs, since that constitutes the criminal offence of dealing in narcotics. Returning the drugs to law enforcement authorities is also prohibited because of professional medical discretion. The only way out of this predicament is for physicians to destroy the drugs under the observation of witnesses.

Common bile duct stenosis in complicated chronic pancreatitis.

BACKGROUND: Common bile duct stenosis (CBDS) is one of the most frequent and serious complications in patients with chronic pancreatitis. Due to improved diagnostic tools, the frequency of CBDS seems to occur more frequently, nevertheless the prevalence varies widely because of different selection criteria. METHODS: Between April 1982 and October 1996, 323 patients with chronic pancreatitis and inflammatory mass in the head of the pancreas (IMH) (286 patients) or CBDS alone (37 patients) were operated. Patients' data including US, CT, ERCP, endocrine and exocrine function tests were documented prospectively. Dividing patients into groups with and without CBDS, clinical data were comparable concerning distribution of sex, age, etiology of the disease and clinical feature. RESULTS: Regarding the subgroup of 286 patients with inflammatory mass in the head of the pancreas (IMH), 154 patients (51%) showed radiological proved CBDS; out of this group, 82 patients (57%) revealed cholestasis and 37 patients (26%) had one or several periods of jaundice. By means of ERCP, 104 patients (72%) revealed short stenosis of the common bile duct (CBD) (<2 cm). No significant differences could be found in terms of morphologic alterations like pancreatic main duct stenosis, pseudocysts, duodenum stenosis, vascular obstruction. Ten patients (7%) in the group with CBDS and 13 patients (9%) in the group without CBDS had cancer in the pancreatic head. Concerning the endocrine function, the group of patients with CBDS had a significantly elevated rate of impaired glucose metabolism (IGT or IDDM) compared to the group without CBDS (60% versus 38%; P < 0.003). These results demonstrate that patients with IMH bear the risk of developing a stenosis of the CBD even before they become symptomatic with cholestasis or jaundice. CONCLUSION: Due to the elevated morbidity and the significantly deteriorated endocrine function, patients of this group are candidates for early surgical treatment.

Local and systemic zymogen activation in human acute pancreatitis.

BACKGROUND: Activation of trypsinogen and phospholipase A(2) is an early event in pancreatic inflammation, but little is known about zymogen activation and the severity of human pancreatitis. METHODS: Using a new fluoroimmunoassay we measured trypsinogen activation peptide (TAP) and phospholipase A(2) activation peptide (PROP) in plasma and ascites in 25 patients with acute pancreatitis. TAP, PROP, Pro-PROP and pancreatic PLA(2)-I were measured in plasma for 14 days and in pancreatic necroses, ascitic fluid and pleural effusions. RESULTS: All 16 patients with severe acute pancreatitis (SAP) had pancreatic necrosis, 10 developed systemic complications like sepsis, pulmonary or renal failure, 6 had infected necrosis, and 4 died. All 9 patients with mild pancreatitis (MAP) survived. Plasma TAP on admission was higher in patients with SAP than in those with MAP and increased in infected necroses. It did not correlate with systemic complications. Systemic PROP was not increased in complicated courses but was significantly higher in patients with MAP than in those with SAP on admission. Pro-PROP was higher in patients with SAP than in those with MAP but was not correlated with systemic complications. Plasma pancreatic PLA(2)-I was increased but not different in patients with SAP and those with MAP. In patients with pancreatic necrosis, TAP and PROP were highest, while in those with post-acute pancreatic abscess, only PROP and Pro-PROP were high. In patients with pleural effusion, TAP was low and PROP/ Pro-PROP were high. CONCLUSION: Trypsinogen and PLA(2)-I activation are early events in acute pancreatitis and the activation peptides can be detected in plasma. In the pancreas, trypsinogen activation is accompanied by PLA(2)-I activation in patients with pancreatic necrosis. However, in our study, organ complications in SAP patients was not associated with increased plasma PROP.

Duodenum-preserving pancreatic head resection in patients with benign and borderline tumors of the pancreatic head.

BACKGROUND: Benign tumors of the pancreas are rare, accounting for only 1-2% of primary pancreatic lesions. Up to now, partial duodenopancreatectomy is still one of the established forms of treatment of benign tumors of the pancreas. We applied duodenum-preserving pancreatic head resection in 12 patients with benign pancreatic tumors to evaluate the feasibility, morbidity and recurrence rates after this less aggressive method. METHODS: Between April 1984 and December 1999, 12 patients with benign and borderline tumors of the pancreatic head were operated on by duodenum-preserving pancreatic head resection. RESULTS: All five patients with serous cystadenoma are free of recurrence 4.4 years after primary resection. One of two patients with mucinous cystadenoma and one of three patients with intraductal papillary mucinous tumor developed recurrent tumor within the former pancreatic head 5 years and 6 years, respectively, after the primary operation. Both patients were resected a second time. One of two patients with gastrinoma still has elevated serum gastrin levels. There was no hospital or long-term mortality. CONCLUSION: For a symptomatic serous cystadenoma, duodenum-preserving pancreatic head resection is a good alternative to partial duodenopancreatectomy. In borderline tumors with malignant potential, we would rather suggest a more radical duodenum-preserving segmental resection. A video clip (3 min) is attached demonstrating the basic steps of duodenum-preserving pancreatic head resection.

Embolization for gastrointestinal hemorrhages.

Retrospective evaluation of interventional embolization therapy in the treatment of gastrointestinal hemorrhage over a long-term observation period from 1989 to 1997. Included in the study were 35 patients (age range 18-89 years) with gastrointestinal bleeding (GI) referred for radiological intervention either primarily or following unsuccessful endoscopy or surgery. Sources of GI bleeding included gastric and duodenal ulcers (n = 7), diverticula (n = 3), erosion of the intestinal wall secondary to malignancy (n = 6), vascular malformations (n = 4), and hemorrhoids (n = 2), as well as from postoperative (n = 6), posttraumatic (n = 2), postinflammatory (n = 4) or unknown (n = 1) causes. Ethibloc (12 cases) or metal coils (14 cases) were predominantly used as embolisates. In addition, combinations of tissue adhesive and gelfoam particles and of coils and Ethibloc were used (six cases). Finally, polyvinyl alcohol particles, a coated stent, and an arterial wire dissection were utilized in one case each. Bleeding was stopped completely in 29 of 35 cases (83%). In one case (3%) the source of bleeding was recognized but the corresponding vessel could not be catheterized. In five other cases (14%) there was partial success with reduced, though still persistent, bleeding. The rate of complications was 14%, including four instances of intestinal ischemia with fatal outcome in the first years, and, later, one partial infarction of the spleen without serious consequences. Gastrointestinal hemorrhage can be controlled in a high percentage of patients, including the seriously ill and those who had previously undergone surgery, with the use of minimally invasive interventional techniques. The availability of minicoils instead of fluid embolization agents has reduced the risk of serious complications.

Platelet-derived growth factors stimulate proliferation and extracellular matrix synthesis of pancreatic stellate cells: implications in pathogenesis of pancreas fibrosis.

At present, the cell-cell interactions and molecular mechanisms of pancreas fibrogenesis are largely unknown. The purpose of this study was to investigate paracrine stimulatory loops between platelets and pancreatic stellate cells (PSC). Human PSC were obtained by outgrowth from fibrotic human pancreas. Native platelet lysate (nPL) and transiently acidified platelet lysate (aPL) were added to cultured PSC (passage 4 to 7) in the absence of serum. The synthesis of collagen types I and III and c-fibronectin (cFN) was demonstrated on protein (immunofluorescence and quantitative immunoassay) and mRNA (Northern blot) level. Using sections of human pancreas with acute pancreatitis, platelet aggregates in capillaries were demonstrated by transmission electron microscopy. nPL, and to an even greater extent aPL, significantly increased the synthesis of collagen types I and III and of c-FN (120 microl/ml aPL increased collagen type I concentration in PSC supernatants by 1.99 +/- 0.17 times and c-FN of 2.49 +/- 0.28 times, mean +/- SD, n = 3). nPL and aPL also significantly stimulated cell proliferation (increased bromodeoxyuridine (BrdU) incorporation by 6.4 +/- 0.78 times and 10 +/- 0.29 times, respectively). By preincubating aPL with transforming growth factor beta (TGFbeta)- and platelet-derived growth factor (PDGF)-neutralizing antibodies and the TGFbeta-latency associated peptide, respectively, TGFbeta1 was identified as the main mediator stimulating matrix synthesis and PDGF as the responsible mitogen. Our data demonstrate that platelets contain fibrogenic mediators that stimulate proliferation (PDGF) and matrix synthesis (TGFbeta1) of cultured PSC. We suggest that platelets and PSC cooperate in the development of pancreas fibrosis.

Lipopolysaccharide-activated macrophages stimulate the synthesis of collagen type I and C-fibronectin in cultured pancreatic stellate cells.

We have recently identified and characterized pancreatic stellate cells (PSC) in rats and humans (Gastroenterology 1998, 15:421-435). PSC are suggested to represent the main cellular source of extracellular matrix in chronic pancreatitis. Now we describe a paracrine stimulatory loop between human macrophages and PSC (rat and human) that results in an increased extracellular matrix synthesis. Native and transiently acidified supernatants of cultured macrophages were added to cultured PSC in the presence of 0.1% fetal calf serum. Native supernatants of lipopolysaccharide-activated macrophages stimulated the synthesis of collagen type I 1.38 +/- 0.09-fold of control and c-fibronectin 1.89 +/- 0.18-fold of control. Transiently acidified supernatants stimulated collagen type I and c-fibronectin 2.10 +/- 0.2-fold and 2.80 +/- 0.05-fold of control, respectively. Northern blot demonstrated an increased expression of the collagen-I-(alpha-1)-mRNA and fibronectin-mRNA in PSC 10 hours after addition of the acidified macrophage supernatants. Cell proliferation measured by bromodeoxyuridine incorporation was not influenced by the macrophage supernatants. Unstimulated macrophages released 1.97 pg TGFbeta1/microgram of DNA over 24 hours and lipopolysaccharide-activated macrophages released 6.61pg TGFbeta1/microgram of DNA over 24 hours. These data together with the results that, in particular, transiently acidified macrophage supernatants increased matrix synthesis, identify TGFbeta as the responsible mediator. In conclusion, our data demonstrate a paracrine stimulation of matrix synthesis of pancreatic stellate cells via TGFbeta1 released by activated macrophages. We suggest that macrophages might play a pivotal role in the development of pancreas fibrosis.

Intraductal papillary mucinous tumor of the pancreas.

BACKGROUND: Since 1996 the classification of pancreatic tumors was replaced by the new World Health Organization nomenclature. Formerly mucinous cystadenomas are now distinguished between intraductal papillary mucinous tumors of the pancreas (IPMT) and mucinous cystadenomas. METHODS: We reevaluated the pathological specimen and surgical therapy of 23 consecutive patients and followed up these patients up for 4 years in median. Between 1987 and 1997 we treated 8 patients with IPMT and 15 patients with mucinous cystadenomas. RESULTS: Eighty-five per cent of all patients were symptomatic. Ultrasonography and computed tomography were the most sensitive diagnostic techniques. In 25%, the entire pancreas was involved with IPMT; that was not the case in any of the patients with mucinous cystadenoma. All patients were resected with no perioperative mortality. After dismissal from the hospital, all resected patients are still alive after a median follow-up of 4 years. In no patient with IPMT, but in 1 patient with mucinous cystadenoma, the tumor recurred. CONCLUSION: Surgical resection is the treatment of choice in all cystic tumors, and the late outcome of IPMT is as good as for mucinous cystadenoma.

Non-operative management of arterial liver hemorrhages.

A retrospective evaluation of embolotherapy in patients with arterial liver hemorrhages was carried out. Twenty-six patients, ranging in age from 10 days to 77 years with active arterial liver hemorrhages, underwent non-surgical embolotherapy. Bleeding was attributed to trauma (n = 21), tumor (n = 3), pancreatitis (n = 1), or unknown cause (n = 1). Twenty-nine embolizations were performed via a transfemoral (n = 26) or biliary (n = 2) approach. One bare Wallstent was placed into the common hepatic artery via to an axillary route to cover a false aneurysm due to pancreatitis. Treatment was controlled in 4 patients by cholangioscopy (n = 2) or by intravascular ultrasound (n = 2). Prior surgery had failed in 3 patients. Intervention controlled the hemorrhage in 24 of 26 (92%) patients within 24 h. Embolotherapy failed in 1 patient with pancreatic carcinoma and occlusion of the portal vein. In 1 patient with an aneurysm of the hepatic artery treated by Wallstent insertion, total occlusion was not achieved in the following days, as demonstrated by CT and angiography. However, colour Doppler flow examination showed no flow in the aneurysm 6 months later. Complications were one liver abscess, treated successfully by percutaneous drainage for 10 days, and one gallbladder necrosis after superselective embolization of the cystic artery. Embolization is a effective tool with a low complication rate in the treatment of liver artery hemorrhage, even in patients in whom surgery has failed.

The surgical management of chronic pancreatitis: duodenum-preserving pancreatectomy.

Duodenum-preserving pancreas resection for chronic pancreatitis results in a subtotal resection of the pancreatic head. Of 488 patients suffering from chronic pancreatitis with an inflammatory mass in the head, 48% had a common bile duct stenosis in the ERCP, 63% had a pancreatic main duct stenosis, 25% had a duodenum stenosis, and 17% showed vascular obstruction--mainly compression or occlusion of the portal vein. Hospital mortality after duodenum-preserving head resection was 0.9%. In the late follow-up, 88% of patients were free of pain and 60% were professionally rehabilitated. The incidence of diabetes mellitus in the late follow-up was 14%; however, 6% of the patients had a lasting improvement of endocrine function. Late mortality after a median follow-up of 6 years (1-22 years after surgical treatment) was 9%. Only 10% of the patients needed further hospitalization due to recurrent attacks of acute pancreatitis. Duodenum-preserving head resection should be the surgical procedure of choice in chronic pancreatitis with an inflammatory mass in the head of the pancreas and in cases with pancreas divisum after failure of medical and interventional treatment. Duodenum-preserving total pancreatectomy is a last-resort surgical treatment after failure of left resection for pain in chronic pancreatitis.

Identification, culture, and characterization of pancreatic stellate cells in rats and humans.

BACKGROUND & AIMS: Until now, the basic matrix-producing cell type responsible for pancreas fibrosis has not been identified. In this report, retinoid-containing pancreatic stellate cells (PSCs) in rat and human pancreas are described, and morphological and biochemical similarities to hepatic stellate cells are shown. METHODS: Electron and immunofluorescence microscopy (collagen types I and III, fibronectin, laminin, alpha-actin, and desmin) was performed using pancreatic tissue and cultured PSCs. Extracellular matrix synthesis was shown using quantitative immunoassay and Northern blot analysis. RESULTS: PSCs are located in interlobular areas and in interacinar regions. Early primary cultured PSCs contain retinol and fatty acid retinyl-esters. Addition of retinol to passaged cells resulted in retinol uptake and esterification. During primary culture, the cells changed from a quiescent fat-storing phenotype to a highly synthetic myofibroblast-like cell expressing iso-alpha-smooth muscle actin (>90%) and desmin (20%-40%) and showing strong positive staining with antibodies to collagen types I and III, fibronectin, and laminin. As determined on protein and messenger RNA level, serum growth factors stimulated the synthesis of collagen type I and fibronectin. CONCLUSIONS: The identification of PSCs, particularly in fibrotic areas, and the similarities of these cells to hepatic stellate cells suggest that PSCs participate in the development of pancreas fibrosis.

Cystic tumours of the pancreas: diagnostic accuracy, pathologic observations and surgical consequences.

BACKGROUND: Cystic neoplasms of the pancreas account for only 1% of primary pancreatic lesions. However, patients with these tumors are diagnosed more frequently. Up to now, nonsurgical management is still the established form of treatment of benign cystic tumours of the pancreas. METHODS: Between 1987 and 1996 we treated 51 patients with serous and mucinous cystadenoma and their malignant counterparts, serous and mucinous cystadenocarcinoma. RESULTS: Eighty-five percent of the patients presented symptoms. Computed tomography and endoscopic cholangiopancreatography (ERCP) were the most sensitive diagnostic techniques; however, in three patients with serous cystadenoma and in one patient with serous cystadenocarcinoma, ERCP findings were completely normal. The tumour was resected in all but one patient. There was no perioperative mortality. After dismissal from the hospital, all patients in whom benign tumours had been resected are still alive; however, the late mortality of mucinous cystadenocarcinoma was 36% after a median follow-up of 6 years. CONCLUSION: Surgical resection is recommended in all cystic tumours, even in serous cystic tumours, because symptoms may develop and malignant transformation to serous cystadenocarcinoma is possible.