Surgery for chronic pancreatitis: what quality of life ahead?

We attempted to evaluate the quality of life of patients with proved long-lasting chronic pancreatitis. We measured the clinical and psychological status of 60 patients who had undergone various surgical treatments for their disease. The presence and severity of depression and other symptoms of distress were assessed, as were disease-specific functional and physical problems. Few patients had serious conditions, such as pain, malnutrition, or psychoneurotic complaints. The relation between depression and the time of onset of symptoms and of surgery appeared doubtful, and no statistically significant correlations were found between severity of emotional disturbance and other functional characteristics. Insulin-dependent diabetes and correlated diseases had the most negative influence on everyday well-being. Postoperative follow-up and the need for recurrent medical control and care did not lead to negative feelings.

Effect of octreotide acetate on pancreatic exocrine and endocrine functions after pancreatoduodenal resection.

In view of forecasting the effect of octreotide acetate (Sandostatin) in preventing fistula formation after pancreatic surgery, 9 patients, who had pancreatoduodenectomy 8-12 days before, underwent a 2-day study. The first day, by means of a catheter located in the jejunal loop separately anastomosed to the pancreatic remnant, basal and after secretin stimulation pancreatic secretion was evaluated. During the 2nd day the possible inhibitory effect of octreotide on basal and stimulated secretion was investigated. Under the experimental conditions of the study Sandostatin showed little effect on the water and bicarbonate increase as stimulated by secretin. A greater hormone inhibitory effect on amylase production and pancreatic endocrine function was seen. On the basis of these results the use of Sandostatin can hardly be seen as useful in preventing fistula formation after pancreatic resection.

Percutaneous CT-guided fine needle aspiration cytology in the differential diagnosis of pancreatic lesions.

Cytologic results were retrospectively evaluated in 83 patients who underwent CT-guided fine-needle aspiration of pancreatic lesions during a 5-year period. Sixty seven patients had malignant disease and 16 benign disease. The sensitivity, specificity, positive and negative predictive values, and diagnostic efficiency of fine-needle aspiration (FNA) cytology in detecting malignancy were 91%, 100%, 100%, 73%, and 93%, respectively. In solid pancreatic masses the sensitivity of FNA cytology rose to 98%, while in cystic pancreatic masses sensitivity fell to 62%. In 18 patients with cystic lesions (12 benign and 6 malignant), the cystic fluid was analyzed for amylase, CEA and CA 19-9 content. Amylase levels were high in pseudocysts and in 4/6 malignant cysts. CEA levels were low in benign cysts, and high in all malignant cysts. CA 19-9 levels were high in one pseudocyst and in all malignant cysts. Tumour marker content analysis enhanced the sensitivity of the cytologic diagnosis of malignant cysts to 92%. FNA cytology is a simple and highly accurate method in the differential diagnosis of solid pancreatic lesions. In cystic lesions, tumour marker fluid content determination increases the sensitivity of FNA cytology.

[Malignant mesenchymal tumors of the breast. Report of 3 new cases]. / Tumori mesenchiamali maligni della mammella. A proposito di tre nuovi casi.

Malignant tumors of the breast arising from the connective tissue of the gland are rare and underestimated. Three new cases are here reported: 1 malignant fibrous histiocytoma and 2 malignant phylloides tumors. Tumor size, mammographic findings and cytologic aspect of the needlebiopsy lead to the correct diagnosis. Large excision or radical mastectomy are treatments of choice, while axillary lymph nodes dissection does not appear justified, since metastatic spread via lymphatics is rare. Postoperative radiation and chemotherapy seem not effective in preventing local recurrences.

Biliary cyst. A case report.

A case of type-IA biliary cyst, according to the Todani classification, is reported in a 44-years-old man admitted to hospital with epigastric pain. Ultrasound was misleading; CT scanning and preoperative cholangiography confirmed the biliary duct's dilatation. Cyst excision and hepaticojejunostomy were performed with a view to avoiding possible cyst cancerization.

[Adrenal cystic masses. Our experience]. / Formazioni cistiche surrenaliche. Nostra esperienza.

Cystic masses of the adrenal gland are clinically and pathologically rare findings and few cases have been reported up to now in the medical literature. In the present work 5 new cases are reported: 3 adrenal pseudocysts, 1 lymphangioma, 1 cystic pheochromocytoma. In 3 cases there were clinical symptoms of retroperitoneal mass (lumbar pain, palpable mass, digestive symptoms); in 3 cases conventional radiology was helpful; ultrasonography was used for diagnosis in 1, CT scan in 2. In the pheochromocytoma case the real nature of the mass was determined through fluid hormone determination after fine needle puncture. All cases were treated by surgery.

[Omeprazole prevention of the recurrence of peptic ulcer: the efficacy of treatment with 20 mg on alternate days]. / Prevenzione con omeprazolo della recidiva di ulcera peptica: validità di un trattamento con 20 mg a giorni alterni.

Omeprazole, 20 mg every second day, in prevention of duodenal ulcer relapse has been tested. 15 patients with peptic ulcer, which was endoscopically proved and then healed, underwent the treatment. No matter of ulcer original seat as well as antacid drug previously employed, recurrences were not seen after a 6 months period, while clinical symptoms and possible adverse reactions appeared to be very slight. The proposed regimen of omeprazole seems to be cost-saving and worth proving.

[Clinical course of diabetes in patients operated upon for chronic pancreatitis]. / Evoluzione del diabete nei pazienti operati per pancreatite cronica.

Diabetes evolution among patients who underwent surgery for chronic pancreatitis has been evaluated (10 had left pancreatectomy, 23 pancreatoduodenectomy, 39 pancreaticojejunostomy, 13 other operations not on the pancreas). On the basis of insulin needs for achieving a normal glycemic status, left pancreatectomy proves to cause or at least to hasten the development of diabetes which appears hardly kept under control and easily followed by complications. The choice of such surgical treatment should be justified, besides the local pathologicoanatomic situation, by a well established endocrine impairment.

A simple method for the determination of lipid composition of human bile.

The Entero-Test, a device for easy sampling of gastrointestinal contents, including bile, has been used for determination of biliary lipid composition. The device consists of a weighted gelatin capsule containing 140 cm of a highly absorbent nylon line. The capsule is swallowed while one end of the string is taped to the face. After 3.5 h, when the line has reached the duodenum, gallbladder contraction is stimulated by intramuscular administration of ceruletide. The line is pulled out, and the last 15 cm are eluted four times in methanol. Total bile acids (by 3 alpha-hydroxysteroid-dehydrogenase assay), individual bile acids (by high performance liquid chromatography), phospholipids (by assay of lipid-soluble phosphorus), and cholesterol (by gas-liquid chromatography) are determined in the eluate. Tests in vitro demonstrated no preferential binding and a good recovery of biliary lipids from the thread. Similar values of biliary cholesterol saturation were obtained by means of duodenal intubation and of the Entero-Test in a series of 12 subjects (r = 0.952). In 5 subjects, individual bile acids were also measured and were found to be similar with both techniques (r = 0.948). When the test was repeated over 3 days in a series of 7 subjects, biliary cholesterol saturation was found to be remarkably reproducible (CV = 7.6%). Thus, the Entero-Test is a convenient technique for the determination of biliary lipid composition, which can be particularly useful in longitudinal studies.

C reactive protein in pancreatic cancer and chronic pancreatitis.

Serum C reactive protein was determined in 30 control subjects, 32 patients with pancreatic cancer, 28 with chronic pancreatitis and 23 with extra-pancreatic diseases of the upper gastrointestinal tract. The aim was to ascertain possible alterations of this index in chronic pancreatic disease and to speculate on some influencing factors. Higher C reactive protein levels were found in pancreatic cancer as compared to controls. Pancreatic cancer patients with systemic metastases had higher levels of this index compared to those with non-metastatic disease. Raised concentrations of C reactive protein were detected in 7/28 subjects with chronic pancreatitis. In this group these higher levels were found in patients in a relapsing phase of the disease; no association was observed with pancreatic pseudocysts. Among all subjects a correlation was found, between C reactive protein and age; patients with abnormal fasting blood glucose levels or increased white blood cell count had higher levels of this protein as compared to the remaining patients. We may conclude that C reactive protein increases in pancreatic cancer, specially in relation to tumour extent; in chronic pancreatitis it reflects the inflammatory status of the gland. While acting in the context of the acute phase response, this test may provide an adjunct in evaluating patients with a chronic pancreatic disease.

Tissue polypeptide antigen, galactosyltransferase isoenzyme II and pancreatic oncofetal antigen serum determination: role in pancreatic cancer diagnosis.

The clinical usefulness of tissue polypeptide antigen, galactosyltransferase II and pancreatic oncofetal antigen was evaluated in detecting pancreatic cancer and in differentiating this malignancy from chronic pancreatitis and other diseases (mainly of the liver and biliary tract) which may enter in differential diagnosis. TPA seems to be the most sensitive among these indices in detecting pancreatic cancer and appears to discriminate this malignancy quite satisfactorily from chronic pancreatitis. It is also frequently pathological in a number of other diseases and is influenced by the presence of liver dysfunction. GT II and POA do not grossly differ from TPA in specificity, but they appear to be less sensitive. Both are frequently pathological in hepato-biliary diseases. All these markers seem, therefore, to be of limited value in the diagnosis of pancreatic cancer.

Transhepatic portal sampling for preoperative localization of insulinomas.

The data of 72 patients with pancreatic insulinomas were analyzed. Twenty-one were obtained from personal experience and 51 from a review of the literature. In all instances, detailed information about insulin levels in the portal tree as obtained by means of a transhepatic portal sampling (THPS) and localization of the tumor as found during the surgical procedure was available. Five different criteria were compared for defining the peak insulin concentrations regarded as indicative of tumor localization: 1, peak above 500 milliunits per liter; 2, peak above 200 milliunits per liter; 3, peak 2.5 times higher than the lowest portal value; 4, peak 2.3 time higher than the distal mesenteric value, and 5, peak higher than mean portal concentration plus or minus 2 standard deviation. Criterion 5, associated with sample numbers larger than 15 and catheterization of the cephalic veins, provided the best results for obtaining valuable information from THPS.

Central venous catheter guidewire replacement according to the Seldinger technique: usefulness in the management of patients on total parenteral nutrition.

While on total parenteral nutrition (TPN), 37 patients underwent replacement of a central venous catheter (CVC), during which a wire introducer was used, according to the Seldinger technique. In 25 patients, the CVC was placed in the superior cava via the subclavian, and, in 12, via the jugular vein. Overall, 82 CVC changes were performed.: 74 for assumed CVC sepsis, 6 as preventive treatment, and 2 for partial catheter displacement. Catheter tip culture proved to be positive in 25 of 119 CVC examined. The catheters were defined as sterile when the tip culture was negative; contaminated, when the tip culture was positive and peripheral blood culture was either negative or positive for different bacteria; septic when both tip and blood were positive for the same bacteria. The results indicated that 10 catheters were contaminated and 17 were septic. Eight previously sterile CVC were found positive after the exchange: 3 were removed at the end of TPN in asymptomatic patients, and 5 were successfully resterilized by means of one more change. Guidewire replacement allowed CVC sterilization of 22 of 24 catheters (91.6%). No complications due to the catheter-changing method were seen.

Evaluation of carbohydrate antigens 19-9 and 12-5 in patients with pancreatic cancer.

The diagnostic value of the tumor-associated antigens Ca 19-9 and Ca 12-5 was tested in 130 subjects (38 healthy controls, 37 carcinomas of the pancreas, 23 chronic pancreatitis, 23 extrapancreatic gastrointestinal cancers, 9 endocrine pancreatic tumors). Ca 19-9 levels above 37 U/ml were obtained in 67.6% and Ca 12-5 levels above 39 U/ml in 45.9% of carcinomas of the pancreas, 4.3 and 8.7%, respectively, of chronic pancreatis, 21.7 and 17.4% of extrapancreatic gastrointestinal tumors, and 0 and 11.1% of endocrine pancreatic tumors and in none of the healthy controls. Results of preoperative determination of Ca 19-9 and Ca 12-5 gave a sensitivity of 67.6 and 45.9%, a specificity of 91.8 and 90.9%, a predictive value of a positive test of 80.6 and 70.8%. When elevation of both antigens was required, sensitivity decreased to 32.4% but specificity rose to 97.3%. All but one of the pancreatic cancer patients were at stage 3 and 4. The only patient with pancreatic cancer in stage 1 had normal levels of both markers. Ca 19-9 and Ca 12-5, whether alone or associated, represent a good diagnostic test for differentiating pancreatic cancer from chronic pancreatitis. Due to the low sensitivity of both markers, the tests are of limited value when any other diagnostic evidence of pancreatic cancer is absent.

Surgical experience with adenocarcinoma of the ampulla of Vater.

Between 1968 and 1982, 13 patients in this study had a pancreaticoduodenectomy (PD), one patient had a total pancreatectomy, two had an ampullectomy, and one patient had a choledochoduodenostomy for neoplasia of the ampulla of Vater. The operative mortality was zero, and the 5-year actuarial survival rate for the 16 resected patients was 52.6 per cent. From a review of the literature, the authors evaluated 1,894 PDs and 61 ampullectomies. The operative mortality rate was 14 per cent and 3 per cent, respectively. The 5-year survival rate was 21 per cent for PD and 23 per cent for ampullectomy. However, 187 patients with negative lymph nodes who underwent PD had a 5-year survival rate of 39 per cent. PD resection is fully warranted for ampullary tumors. Ampullectomy should be reserved only for high surgical risk patients.

An unusual complication of chronic pancreatitis: a recanalized portal tree communicating with a pancreatic pseudocyst.

A patient with chronic pancreatitis was admitted for digestive bleeding from esophageal varices. Portal thrombosis and cavernomatous periportal collateral circulation were found at laparotomy. The partially recanalized portal tree was excluded from the portal circulation and filled with pancreatic juice due to a communication with a pancreatic pseudocyst. Splenectomy, partial left pancreatectomy, Roux en Y pancreatico-cysto-jejunostomy, and external drainage of the portal tree were performed. The postoperative course was uneventful and the patient is symptom-free and doing well 2 yr after surgery.