The Physiological Incubation Biosimulator (PIBS): An Improved Ex Vivo Experimental Setup for the Mechanical Stability of Biological Sealants in Surgical Procedures.

BACKGROUND: Tissue-bound fibrin sealants are used in a wide array of surgical procedures. The microenvironmental interaction between sealant and application site is often poorly evaluated due to a lack of suitable experimental models. METHODS: A physiological incubation biosimulator (PIBS) was developed to test biological sealants in an ex vivo setup under physiological conditions comparable to the microenvironment at application site (temperature, humidity, pressure). PIBS was validated by a study on the effectiveness of TachoSil for leak closure at pancreatic resection sites. Defined defects in a thoracic membrane of porcine origin were sealed by TachoSil. Integrity of the sealing was tested in the presence of active pancreatic fluid over 60 minutes. Heat-inactivated pancreatic fluid and electrolyte solution served as controls. The time to leakage was recorded and experimental groups were analyzed by Kaplan-Meier analysis. RESULTS: PIBS produced reliable results. TachoSil lead to a leakage rate of 96% after incubation with active pancreatic fluid (p = 34), which was significantly higher compared with heat-inactivated pancreatic fluid (p = 34, 52%) or electrolyte solution (p = 20, 19%). CONCLUSION: PIBS is an effective tool to evaluate microenvironmental effects on the adhesive strength of biomaterials. Tissue sealing effect of TachoSil is diminished in a "pancreatic" microenvironment rich with pancreatic enzymes. Our results might therefore explain the reason of the findings of randomized controlled trials recently published on this subject.

The Impact of Bile Duct Cultures on Surgical Site Infections in Pancreatic Surgery.

INTRODUCTION: In pancreatic surgery pre-operative biliary drainage (PBD) is associated with bacteribilia, which increases the risk for surgical site infections (SSIs). METHODS: This study is a retrospective observational cohort design that compared micro-organisms of intra-operative bile duct cultures with micro-organisms of SSIs after pancreaticoduodenectomy. RESULTS: From January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy or hepaticojejunostomy for benign and malignant peri-ampullary lesions. Surgical site infections occurred in 10% (87/887). Cultures of SSIs with corresponding intra-operative bile duct cultures were available for 59 patients. Sixty-four percent (38/59) had undergone PBD. Pre-operative biliary drainage was associated with positive intra-operative bile duct cultures in 95% (36/38), versus 48% (10/21; p≤0.001). The correlation of SSIs with intra-operative bile duct cultures was 59% (35/59). There was a significant association between the micro-organisms cultured from SSIs and the corresponding bile duct cultures for Enterococcus spp., Escherichia coli, Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae with extended spectrum ß-lactamase (ESBL), and Candida spp. CONCLUSION: After pancreaticoduodenectomy, SSIs are often caused by the same micro-organisms that are present on intra-operative bile duct cultures, especially after PBD. Therefore, intra-operative bile duct cultures should be performed routinely to adjust the antibiotic prophylaxis according to the local hospital surveillance data.

Surgical revision of hepaticojejunostomy strictures after pancreatectomy.

BACKGROUND: After pancreatic surgery hepaticojejunostomy (HJ) stricture is a rare condition. Usually, management is conservative, while operative revision ("redo") is only rarely performed. METHODS: This was an observational cohort design that analyzed the outcome of patients who had a surgical revision of HJ strictures after pancreatic surgery at a specialized pancreatic center. RESULTS: During a period of 7 years from January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy (PD) or HJ. Among this patient population, 3 % (23/887) underwent a redo of the HJ secondary to stricture formation. Major symptoms of HJ strictures were recurrent cholangitis in 91 % (21/23) and jaundice in 39 % (9/23). The median time from the index operation until redo of the HJ was 16 ± 27 months. The median survival of patients with malignancy after redo of the HJ was 45 ± 67 months. Major surgical morbidity was 9 % (2/23), and mortality was 0 % (0/23). In 78 % (18/23), there were no further episodes of cholangitis after a median follow of 49 ± 73 months, while none of the patients with redo of the HJ developed a restenosis of the HJ. CONCLUSION: Surgical revision (redo) of HJ strictures can be safely performed by an experienced pancreatic surgeon with a low morbidity without mortality with good long-term results.

Management of isolated bile leaks after pancreatic resections.

INTRODUCTION: After pancreatectomy, an isolated bile leak from the hepaticojejunostomy is a severe surgical complication that is underrepresented both, in the literature and in the awareness of pancreatic surgeons. The goal of this study was to analyze the incidence and outcome of isolated bile leaks after pancreatectomy. MATERIAL AND METHODS: A retrospective study of patients who underwent duodenopancreatectomy or total pancreatectomy at a single-center institution was performed, which analyzed incidence and course of patients with postoperative bile leaks from the hepaticojejunostomy. RESULTS: During a period of 42 months, 209 patients underwent pancreatic head resection or total pancreatectomy. Bile leaks occurred in 4% (8/209) and were more common in patients with distal bile duct cancer. Bile leaks led to longer hospital stay and were associated with abscess formation and other infectious complications. Unlike expected, most postoperative bile leaks occurred in the late postoperative period. Three patients required relaparotomy for biliary peritonitis or delayed visceral hemorrhage, while the other five patients underwent conservative management, including CT drainage and antibiotic therapy. One patient with a postoperative bile leak died due to delayed visceral hemorrhage. CONCLUSION: In contrast to recently published data, isolated postoperative bile leaks after pancreatectomy often occur in the late postoperative period and more frequently require a relaparotomy than the literature suggests. The presented study results may sensitize surgeons for this often disregarded topic and activate the discussion on treatment options.

The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube.

BACKGROUND: After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS: A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS: In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS: Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.

The impact of JNK inhibitor D-JNKI-1 in a murine model of chronic colitis induced by dextran sulfate sodium.

PURPOSE: The c-Jun N-terminal kinases (JNK) are involved in the activation of T cells and the synthesis of proinflammatory cytokines. Several studies have established the relevance of the JNK pathway in inflammatory bowel diseases. The present study analyzed the therapeutic effect of D-JNKI-1, a specific JNK-inhibiting peptide, in a low-dose dextran sulfate sodium (DSS) model of chronic colitis. METHODS: DSS colitis was induced in female C57/BL6 mice by cyclic administration using different concentrations of DSS (1.0% and 1.5%). Mice in the intervention groups received subcutaneous administration of 1 µg/kg D-JNKI-1 on days 2, 12, and 22. They were monitored daily to assess the severity of colitis, body weight, stool consistency, and the occurrence of occult blood or gross rectal bleeding using evaluation of the disease activity index. The animals were sacrificed after 30 days, and the inflamed intestine was histologically evaluated using a crypt damage score. Immunohistochemical quantification of CD4(+) and CD8(+) cells was also carried out. RESULTS: Administration of 1 µg/kg D-JNKI-1 resulted in a significant decrease in the disease activity index (P = 0.013 for 1.0% DSS; P = 0.007 for 1.5% DSS). As a mild form of colitis was induced, histological examination did not show any distinct damage to the mucosa and crypts. However, expression of CD4(+) and CD8(+) cells was reduced in mice treated with D-JNKI-1 (not significant). CONCLUSION: Administration of D-JNKI-1 resulted in a clinical attenuation of chronic DSS colitis, and a therapeutic effect of D-JNKI-1 must therefore be assumed. The decrease in CD4(+) and CD8(+) cells may reflect the influence of D-JNKI-1 on T-cell activation, differentiation, and migration.

Quantitative assessment and determinants of suture-holding capacity of human pancreas.

BACKGROUND: Hard pancreas is welcome by surgeons performing resective pancreatic surgery, because it is believed to offer better suture holding capacity (SHC), thus decreasing the risk for a postoperative leak. However, neither the actual SHC of pancreatic tissue in humans nor its determinants have been studied. METHODS: We directly measured SHC for polydioxanone 5-0 suture and tissue hardness at the pancreatic isthmus in 53 human pancreata using a dynamometer and a durometer. A histologic score based on fibrosis grade, fat content, pancreatic duct size, and signs of chronic pancreatitis was calculated for every sample. We tested the hypothesis that SHC of the pancreas was proportional to tissue hardness, and evaluated the role of different possible histomorphologic determinants of SHC. RESULTS: Suture-holding capacity correlated perfectly with tissue hardness (r = 0.98; P < 0.001; 95% confidence interval, 0.96-0.99). The histologic score showed a stronger correlation with both parameters than any single histologic parameter. The SHC of transductal sutures was significantly higher than that of pure transparenchymal sutures. The SHC and hardness were significantly lower in patients who developed a clinically relevant pancreatic fistula postoperatively. CONCLUSIONS: A mixture of histomorphologic features of human pancreas determines its tissue hardness and SHC. Involvement of the main pancreatic duct in the suture line appears to increase the mechanical strength of the pancreatic anastomosis.

Early and late postoperative changes in the quality of life after pancreatic surgery.

PURPOSE: To compare health-related quality of life (QoL) before and after surgery for pancreatic disease. METHODS: A retrospective analysis of prospectively gathered data is presented. A total of 174 patients of 230 planned for pancreatic surgery between March and December 2009 at a German high-volume center completed the Short Form-36 (SF-36) Health Survey preoperatively, 133 of them at 3 months and 83 at 24 months after surgery. Data was analysed according to diagnosis and procedure, and compared to German population norms. RESULTS: QoL in the study group was worse than that of age-matched healthy population at all time points. It decreased continuously in the cancer group, decreased early and showed a trend toward recovery late in patients with benign tumors and chronic pancreatitis. Distal pancreatectomy was the best tolerated and total pancreatectomy the worst tolerated procedure. Older age and development of pancreatic insufficiency affected negatively QoL. CONCLUSIONS: In patients with pancreatic disease, diagnosis determined QoL preoperatively and late after surgery, while in the early postoperative period, type and extent of surgery was the leading factor. Total pancreatectomy had a profound negative effect on QoL and should be reserved for carefully selected patients only.

Knockout of the c-Jun N-terminal Kinase 2 aggravates the development of mild chronic dextran sulfate sodium colitis independently of expression of intestinal cytokines TNFα, TGFB1, and IL-6.

INTRODUCTION: The c-Jun N-terminal kinases (JNKs) are involved in signal transduction of inflammatory bowel diseases. The aim of this study was to examine the function of JNKs by using a low-dose dextran sulfate sodium (DSS) model in JNK1 knockout mice (Mapk8-/-), JNK2 knockout mice (Mapk9-/-), and wild-type controls (WT1, WT2). METHODS: The animals were evaluated daily using a disease activity index. After 30 days, the intestine was evaluated histologically with a crypt damage score. CD4+ and CD8+ cells were quantified using immunofluorescence. Analysis of tumor necrosis factor-α (TNFα), interleukin-6 (IL-6), and transforming growth factor ß1 (TGFB1) expression was carried out using LightCycler(®) real-time polymerase chain reaction. RESULTS: Cyclic administration of low-dose DSS (1%) was not able to induce features of chronic colitis in Mapk8-/- WT2 mice. By contrast, DSS administration significantly increased the disease activity index in WT1 and Mapk9-/- mice. In Mapk9-/- mice, the crypt damage score and the number of CD4+ and CD8+ cells as features of chronic colitis/inflammation were also significantly elevated. Expression of TNFα, IL-6, and TGFB1 was not altered by the JNK knockout. CONCLUSION: Administering DSS at a defined low concentration that is unable to induce colitis in WT animals leads to clinically and histologically detectable chronic colitis in Mapk9-/- mice. The reason for this disease-inducing effect resulting from the loss of JNK2 remains to be elucidated. Expression of TNFα, IL-6, and TGFB1 does not appear to be involved; proapoptotic JNK2 may prolong the activity of proinflammatory immune cells, leading to perpetuation of the inflammation.

Pancreatic surgery in the very old: face to face with a challenge of the near future.

BACKGROUND: The proportion of octogenarians requiring surgery for pancreatic disease is rapidly growing. This trend will be continued during the next decades, posing a challenge to surgeons and the health care system worldwide. This study aimed to analyze the results of pancreatic surgery in octogenarians in terms of safety and survival based on a cohort of patients at a European high-volume center. METHODS: During a 7-year period, 1,705 operations were performed, 76 in patients ≥ 80 years of age. Data on the octogenarians were retrospectively reviewed and compared to those of the whole collective and to contemporary data from the literature. Primary endpoints were mortality, morbidity, and survival. RESULTS: Overall, 80 % had a malignant disease, and resections were performed in 50 % of all cases. Mortality was 11.8 % and morbidity 72.4 %. There were significantly more medical than surgical complications: 56.6 versus 34.2 %. Pancreatic fistula occurred in 5.3 %, postoperative bleeding in 3.9 %, and delayed gastric emptying in 19.7 %. The median hospital stay was 15 days and the intensive care unit stay 2 days. Mean survival was 28.2 months and in patients with cancer 22.6 months. The 1-, 3-, and 5-year survival rates were 61.4, 31.3, and 18.8 %, respectively. CONCLUSIONS: Despite high mortality and morbidity rates, surgery remains the only chance for cure in most octogenarians with pancreatic disease. Careful patient selection is the key to success and improved long-term survival in this group, which will represent a substantial fraction of the population in the near future.

Circulating U2 small nuclear RNA fragments as a novel diagnostic biomarker for pancreatic and colorectal adenocarcinoma.

Improved non-invasive strategies for early cancer detection are urgently needed to reduce morbidity and mortality. Non-coding RNAs, such as microRNAs and small nucleolar RNAs, have been proposed as biomarkers for non-invasive cancer diagnosis. Analyzing serum derived from nude mice implanted with primary human pancreatic ductal adenocarcinoma (PDAC), we identified 15 diagnostic microRNA candidates. Of those miR-1246 was selected based on its high abundance in serum of tumor carrying mice. Subsequently, we noted a cross reactivity of the established miR-1246 assays with RNA fragments derived from U2 small nuclear RNA (RNU2-1). Importantly, we found that the assay signal discriminating tumor from controls was derived from U2 small nuclear RNA (snRNA) fragments (RNU2-1f) and not from miR-1246. In addition, we observed a remarkable stability of RNU2-1f in serum and provide experimental evidence that hsa-miR-1246 is likely a pseudo microRNA. In a next step, RNU2-1f was measured by qRT-PCR and normalized to cel-54 in 191 serum/plasma samples from PDAC and colorectal carcinoma (CRC) patients. In comparison to 129 controls, we were able to classify samples as cancerous with a sensitivity and specificity of 97.7% [95% CI = (87.7, 99.9)] and 90.6% [95% CI = (80.7, 96.5)], respectively [area under the ROC curve 0.972]. Of note, patients with CRC were detected with our assay as early as UICC Stage II with a sensitivity of 81%. In conclusion, this is the first report showing that fragments of U2 snRNA are highly stable in serum and plasma and may serve as novel diagnostic biomarker for PDAC and CRC for future prospective screening studies.

Rare solid tumors of the pancreas as differential diagnosis of pancreatic adenocarcinoma.

CONTEXT: Rare solid tumors of the pancreas can be misinterpreted as primary pancreatic cancer. OBJECTIVE: The aim of this study was to report our experience in the treatment of patients with rare tumor lesions of the pancreas and to discuss clinical and pathological characteristics in the context of the role of surgery. DESIGN: Data from patients of our prospective data-base with rare benign and malignant tumors of the pancreas, treated in our division from January 2004 to August 2010, were analyzed retrospectively. RESULTS: One-thousand and ninety-eight patients with solid tumors of the pancreas underwent pancreatic surgery. In 19 patients (10 women, 9 men) with a mean age of 57 years (range: 20-74 years) rare pancreatic tumors (metastasis, solid pseudopapillary tumor, teratoma, hemangioma, accessory spleen, lymphoepithelial cyst, hamartoma, sarcoidosis, yolk sac tumor) were the reason for surgical intervention. CONCLUSION: If rare benign and malignant pancreatic tumors, intrapancreatic metastasis, as well as pancreatic malformations or other abnormalities, present themselves as solid masses of the pancreas, they constitute an important differential diagnosis to primary pancreatic neoplasia, e.g. pancreatic ductal adenocarcinoma. Clinical imaging techniques cannot always rule out malignancy, thus operative exploration often remains the treatment of choice to provide the correct diagnosis and initiate adequate surgical therapy.

Global microRNA expression profiling of microdissected tissues identifies miR-135b as a novel biomarker for pancreatic ductal adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is known for its poor prognosis resulting from being diagnosed at an advanced stage. Accurate early diagnosis and new therapeutic modalities are therefore urgently needed. MicroRNAs (miRNAs), considered a new class of biomarkers and therapeutic targets, may be able to fulfill those needs. Combining tissue microdissection with global miRNA array analyses, cell type-specific miRNA expression profiles were generated for normal pancreatic ductal cells, acinar cells, PDAC cells derived from xenografts and also from macrodissected chronic pancreatitis (CP) tissues. We identified 78 miRNAs differentially expressed between ND and PDAC cells providing new insights into the miRNA-driven pathophysiological mechanisms involved in PDAC development. Having filtered miRNAs which are upregulated in the three pairwise comparisons of PDAC vs. ND, PDAC vs. AZ and PDAC vs. CP, we identified 15 miRNA biomarker candidates including miR-135b. Using relative qRT-PCR to measure miR-135b normalized to miR-24 in 75 FFPE specimens (42 PDAC and 33 CP) covering a broad range of tumor content, we discriminated CP from PDAC with a sensitivity and specificity of 92.9% [95% CI=(80.5, 98.5)] and 93.4% [95% CI=(79.8, 99.3)], respectively. Furthermore, the area under the curve (AUC) value reached of 0.97 was accompanied by positive and negative predictive values of 95% and 91%, respectively. In conclusion, we report pancreatic cell-specific global miRNA profiles, which offer new candidate miRNAs to be exploited for functional studies in PDAC. Furthermore, we provide evidence that miRNAs are well-suited analytes for development of sensitive and specific aid-in-diagnosis tests for PDAC.

Apoptosis in esophagus and pancreas carcinoma cells induced by circulating microparticles is related to phosphatidyl serine and microparticle-associated caspases.

Circulating microparticles (MPs) are recently discussed as "biologically active", participating in the pathology of diseases rather than being a marker of damaging processes. It was the purpose of the present study to investigate the effects of MPs, as isolated from the blood of healthy volunteers, on the induction of apoptosis and necrosis in cultured KYSE-270 esophageal and ASPC1 pancreas carcinoma cells. MPs were obtained from the blood of 20 healthy volunteers (11 women; mean age 33.3 years). Viability, apoptosis, and necrosis were determined by flow cytometry using Annexin V/propidium iodide and tetramethylrhodamine ethyl ester perchlorate (TMRE)/propidium iodide for staining. Incubation of KYSE and ASPC1 carcinoma cells with MPs (1-20.000/µl) for 48 h reduced significantly viability of the cells, and induced apoptosis, but not necrosis. This apoptotic effect was significant at a concentration of ≥1.000 MPs/µl in both cell types. Pre-treatment of MPs with either the global caspase inhibitor ZVAD-FMK or Annexin V which blocks phosphatidyl serine in the outer membrane of MPs with high affinity, almost abolished MP-induced apoptosis. A specific enzyme assay as well Western blot analysis confirmed the presence (activity, protein) of the apoptotic enzyme caspase-3 in MPs. Incubation of carcinoma cells with MPs (20.000/µl) resulted in an increase in caspase-3 protein in carcinoma cells; this increase could be prevented by pre-treatment of MPs with Annexin V. It is suggested that MPs induce concentration-dependent apoptosis in KSYE esophageal and ASPC1 pancreas carcinoma cells in vitro by transferring caspases into target cells. This process probably requires a target cell-MP interaction, and membrane-bound anionic phosphatidyl serine may be involved.

Gene expression analysis of cell death induction by taurolidine in different malignant cell lines.

BACKGROUND: The anti-infective agent Taurolidine (TRD) has been shown to have cell death inducing properties, but the mechanism of its action is largely unknown. The aim of this study was to identify potential common target genes modulated at the transcriptional level following TRD treatment in tumour cell lines originating from different cancer types. METHODS: Five different malignant cell lines (HT29, Chang Liver, HT1080, AsPC-1 and BxPC-3) were incubated with TRD (100 µM, 250 µM and 1000 µM). Proliferation after 8 h and cell viability after 24 h were analyzed by BrdU assay and FACS analysis, respectively. Gene expression analyses were carried out using the Agilent-microarray platform to identify genes which displayed conjoint regulation following the addition of TRD in all cell lines. Candidate genes were subjected to Ingenuity Pathways Analysis and selected genes were validated by qRT-PCR and Western Blot. RESULTS: TRD 250 µM caused a significant inhibition of proliferation as well as apoptotic cell death in all cell lines. Among cell death associated genes with the strongest regulation in gene expression, we identified pro-apoptotic transcription factors (EGR1, ATF3) as well as genes involved in the ER stress response (PPP1R15A), in ubiquitination (TRAF6) and mitochondrial apoptotic pathways (PMAIP1). CONCLUSIONS: This is the first conjoint analysis of potential target genes of TRD which was performed simultaneously in different malignant cell lines. The results indicate that TRD might be involved in different signal transduction pathways leading to apoptosis.

Synergistic effects of sonoporation and taurolidin/TRAIL on apoptosis in human fibrosarcoma.

Sonodynamic therapy, in combination with ultrasound contrast agents, proved to enhance the uptake of chemotherapeutics in malignant cells. HT1080 fibrosarcoma cells were treated in vitro with a combination of ultrasound SonoVue™-microbubbles and taurolidine (TRD) plus tumor necrosis factor related apoptosis inducing ligand (TRAIL). Apoptosis was measured by TdT-mediated dUTP-biotin nick end labelling (TUNEL) assay and fluorescence activated cell sorting (FACS) analysis. Gene expression was analysed by RNA-microarray. The apoptotic effects of TRD and TRAIL on human fibrosarcoma are enhanced by sonodynamic therapy and additional application of contrast agents, such as SonoVue™ by 25%. A broad change in the expression of genes related to apoptotic pathways is observed when ultrasound and microbubbles act synchronously in combination with the chemotherapeutics (e.g. BIRC3, NFKBIA and TNFAIP3). Some of these genes have already been proven to play a role in programmed cell death in human fibrosarcoma (HSPA1A/HSPA1B, APAF1, PAWR, SOCS2) or were associated with sonication induced apoptosis (CD44). Further studies are needed to explore the options of sonodynamic therapy on soft tissue sarcoma and its molecular mechanisms.

Indications and early outcomes for total pancreatectomy at a high-volume pancreas center.

BACKGROUND: This study aimed to analyse the most common current indications for total pancreatectomy (TP) at a high-volume pancreas center. METHOD: Prospectively collected data on indications and short-term outcome of all TP's performed from January 2004 until June 2008 were analysed. RESULTS: The total pancreatectomies (TP) were 63, i.e., 6.7% of all pancreatic procedures (n = 948). Indications for TP were classified into 4 groups: tumors of advanced stage, n = 23 (36.5%), technical problems due to soft pancreatic tissue, n = 18 (28.6%), troubles due to perioperative surgical complications, n = 15 (23.8%), and therapy-resistant pain due to chronic pancreatitis, n = 7 (11.1%). Surgical complications occurred in 23 patients (36.5%). The mortality in elective TP was 6.25%. Median postoperative stay was 21 days. Mortality, morbidity and the other perioperative parameters differed substantially according to the indication for pancreatectomy. CONCLUSION: Total pancreatectomy is definitely indicated for a limited range of elective and emergency situations. Indications can be: size or localisation of pancreatic tumor, trouble, technical diffuculties and therapy-refractory pain in chronic pancreatitis. A TP due to perioperative complications (troubles) after pancreatic resections is doomed by extremely high morbidity and mortality and should be avoided.

Comparative analysis of cell death induction by Taurolidine in different malignant human cancer cell lines.

BACKGROUND: Taurolidine (TRD) represents an anti-infective substance with anti-neoplastic activity in many malignant cell lines. So far, the knowledge about the cell death inducing mechanisms and pathways activated by TRD is limited. The aim of this study was therefore, to perform a comparative analysis of cell death induction by TRD simultaneously in different malignant cell lines. MATERIALS AND METHODS: Five different malignant cell lines (HT29/Colon, Chang Liver/Liver, HT1080/fibrosarcoma, AsPC-1/pancreas and BxPC-3/pancreas) were incubated with increasing concentrations of TRD (100 microM, 250 microM and 1000 microM) for 6 h and 24 h. Cell viability, apoptosis and necrosis were analyzed by FACS analysis (Propidiumiodide/AnnexinV staining). Additionally, cells were co-incubated with the caspase Inhibitor z-VAD, the radical scavenger N-Acetylcystein (NAC) and the Gluthation depleting agent BSO to examine the contribution of caspase activation and reactive oxygen species in TRD induced cell death. RESULTS: All cell lines were susceptible to TRD induced cell death without resistance toward this anti-neoplastic agent. However, the dose response effects were varying largely between different cell lines. The effect of NAC and BSO co-treatment were highly different among cell lines--suggesting a cell line specific involvement of ROS in TRD induced cell death. Furthermore, impact of z-VAD mediated inhibition of caspases was differing strongly among the cell lines. CONCLUSION: This is the first study providing a simultaneous evaluation of the anti-neoplastic action of TRD across several malignant cell lines. The involvement of ROS and caspase activation was highly variable among the five cell lines, although all were susceptible to TRD induced cell death. Our results indicate, that TRD is likely to provide multifaceted cell death mechanisms leading to a cell line specific diversity.

Redo-surgery following curative resection of pancreatic carcinoma: the difference between true and suspected recurrence.

BACKGROUND: Improving results have led to an extension of indications for re-resection of recurrent pancreatic carcinoma. METHODS: Among 410 patients who received surgery for histologically proven pancreatic cancer, 17 underwent re-resection for a suspected local recurrence and were evaluated for overall survival, clinicopathological and perioperative data. RESULTS: At the initial operation, resection was curative (R0/R1) in all 17 patients. Indication for re-resection was a suspected or proven recurrence of pancreatic cancer in all patients. Re-resection was possible in 5 patients. The remaining patients received a redo of the pancreaticojejunostomy or bilioenteric anastomosis (n = 2), exploration with biopsy (n = 4), and a palliative bypass (n = 6). Perioperative mortality was 6%. Median overall survival was 25 months (range 10-152 months) and 7 months following re-resection (5-29 months). In 5 of 17 patients, histology showed chronic pancreatitis (n = 4) or a benign stricture at the hepaticojejunostomy (n = 1), whereas all other patients had histologically proven recurrence. Re-resection or redo of the anastomosis was possible in 5 of 5 patients with chronic pancreatitis but only in 2 of 12 patients with true recurrence (p = 0.003). CONCLUSIONS: Curative reoperation for recurrent pancreatic carcinoma is rarely feasible. Due to the potential for chronic pancreatitis or benign strictures as an underlying pathology, operable patients should be explored.

Identification of patients at risk for development of tertiary peritonitis on a surgical intensive care unit.

BACKGROUND: Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP. STUDY DESIGN: Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period. RESULTS: Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO. CONCLUSIONS: The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis.