Search

Background and Aims: Distal pancreatectomy is the only effective treatment for cancers of the pancreatic body and tail. The recurrence rate after DPhas remained high. In an effort to overcome this problem, we developed a no-touch surgical technique for DP. This is a pilot study to see if distal pancreatectomy can be technically done using a no-touch surgical technique without deteriorating the post-operative prognosis.Patients and Methods: From November 2000 through May 2011, 16 pancreatic ductal adenocarcinoma patients have been operated on using a no-touch technique by a single operator. We described the surgical technique, and we reported our preliminary experience. During the procedure, the pancreatic body and tail is neither grasped nor squeezed by the surgeon. And all drainage vessels from the pancreatic body and tail are ligated and divided during the early phase of the operation. Furthermore, for improved dissection of the retroperitoneal tissue (rightward and posterior margins), we use a hanging and clamping maneuver and dissection behind Gerota's fascia.Results: In the current series, the posterior and rightward resection margins were free in all patients, although seven were positive for anterior serosal invasion. The post-operative prognosis was not deteriorated with this technique.Conclusion: No-touch distal pancreatectomy technique may have some theoretical advantages, which merit future investigation in randomized controlled trials.

Understanding of the relation between the alcoholic consumption and the development of pancreatitis should help in defining the alcoholic etiology of pancreatitis. Although the association between alcohol consumption and pancreatitis has been recognized for over 100 years, it remains still unclear why some alcoholics develop pancreatitis and some do not. Surprisingly little data are available about alcohol amounts, drinking patterns, type of alcohol consumed and other habits such as dietary habits or smoking in respect to pancreatitis preceding the attack of acute pancreatitis or the time of the diagnosis of chronic pancreatitis. This review summarizes the current knowledge. Epidemiological studies clearly show connection between the alcohol consumption in population and the development of acute and chronic pancreatitis. In the individual level the risk to develop either acute or chronic pancreatitis increases along with the alcohol consumption. Moreover, the risk for recurrent acute pancreatitis after the first acute pancreatitis episode seems also to be highly dependent on the level of alcohol consumption.

The number of small and often asymptomatic cystic lesions detected in pancreas has increased during the last decade. Historically the vast majority of the pancreatic cystic lesions were considered pseudocysts, but in recent series the incidence of various neoplastic cysts, such as intraductal papillary mucinous neoplasm, serous cystadenomas and cystic endocrine tumours, has increased. The possible malignant potential in these cystic neoplasms warrants careful diagnostic workup to choose the optimal treatment for each patient. Patient's age, symptoms and a possible history of acute or chronic pancreatitis with known aetiology together with high quality imaging studies are important in the differential diagnosis between pseudocysts and neoplastic cysts. Endoscopic ultrasound, cyst fluid analysis and positron emission tomography may be used in selected patients, but the accuracy of these methods needs further investigation.

Purpose: It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.Methods: A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.Results: The site of superficial reflux was at the groin in 58 % (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11 % (unoperated short saphenous vein). In 58 % of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74 % of the legs, sensation of oedema in 64 %, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2–3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2–3) were significantly more frequent among complicated legs (CEAP clinical class C2–3: 22% versus CEAP clinical class C4–6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7 % versus severe reflux: 48 %; p < 0.005).Conclusions: Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

The effect of lesser sac drainage with or without lavage on some early predictors and on outcome in acute necrotizing pancreatitis was analysed. The evaluation was made prospectively for 24 patients, in a single centre study. According to Ranson's criteria and laparotomy findings, the lavage and drainage groups were comparable and the pancreatitis was severe and necrotizing in both groups. In a longitudinal analysis of the first 4 postoperative days, lavage did not show any advantage over drainage, as measured by seven prognostic signs (serum creatinine, blood glucose, base excess, haematocrit, white blood cells, C-reactive protein and immunoreactive phospholipase A2concentration). Furthermore, the study did not find that lavage had any positive effect on the incidence of mortality (36 versus 17 per cent in the drainage group) or on septic complications in acute necrotizing pancreatitis. In the total series the extent of pancreatic necrosis was an essential predictor of the outcome.

Abstract: Angiosarcoma is a rare tumor in the small bowel. Several predisposing factors have been suggested, including external irradiation for another malignancy. Only six cases of small-bowel angiosarcoma in patients previously treated with pelvic irradiation for gynecological malignancies have been reported hitherto. We present here two patients in whom a diagnosis of small-bowel angiosarcoma was made 10 years or more after intrapelvic irradiation. These cases demonstrate poor prognosis in this disease. Although postirradiation angiosarcoma is a rare condition, its possibility should be kept in mind when operating on previously irradiated patients.

Abstract.: The sensitivity and specificity of ultrasonography in detection of free intraperitoneal fluid is over 90 %. The lowest detectable volume of free fluid in humans is unknown. The distribution of intraperitoneal fluid was studied in 86 patients by transabdominal US in group A (n = 21, 10 ml of fluid), in group B (n = 15, 50 ml of fluid) and group C (n = 50, splenic trauma). Ultrasound detected fluid in 15 of 21 patients in group A, and in all patients in groups B and C. In group A 10 ml of fluid was found in 71 % of cases behind the bladder, and in only 5–14 % of cases in the upper abdomen. In group B 50 ml of fluid was found in all patients in the lower pelvis, but in only 20 % in Morison's pouch and in 7 % around the spleen. In group C 200–4500 ml of fluid was detected by US in 72 % of patients in the perisplenic space, in 60 % in Morison's pouch and in 42 % in the retrovesical space. Small volumes of free intraperitoneal fluid (10–50 ml) can be detected with current US scanners, but only near the site of injury. These results support the role of US as a primary imaging modality in abdominal trauma.

Tumour necrosis factor (TNF) is an early mediator of sepsis and multiple organ failure; increased concentrations in serum are also observed in acute pancreatitis. In the present study the predictive value of TNF and C-reactive protein (CRP) concentrations on admission were compared in order to differentiate complicated cases of acute pancreatitis from the mild course in 77 patients. Serum TNF concentration exceeded the detectable level only in seven of 77 patients (9 per cent), although complicated pancreatitis developed in 18 (23 per cent). The sensitivity and overall accuracy of TNF concentration in predicting severe disease were only 16 and 74 per cent respectively. The corresponding values for CRP (concentrations greater than 100 mg/1) were 84 and 74 per cent respectively. These data suggest that, in contrast with CRP, the early determination of peripheral blood TNF concentration is of no clinical value in assessing the severity of acute pancreatitis.

The influence of pancreatic resection on early systemic complications of acute necrotizing pancreatitis was evaluated in 84 patients. The aetiology of pancreatitis was alcohol 71 per cent, gallstones 13 per cent, alcohol plus gallstones 2 per cent, trauma 1 per cent and idiopathic 12 per cent. A total of 26 of 81 patients (32 per cent) had greater than 50 per cent pancreatic necrosis and 9 patients (11 per cent) considered to have parenchymal necrosis at operation had none shown histologically. The overall mortality was 38/84 (45 per cent) and mortality during the first postoperative week was 15/84 (18 per cent). The outcome after early and delayed operation did not differ significantly. Pancreatic resection had no beneficial effect on shock or respiratory or renal failure (respective pre-operative incidence 12 per cent, 11 per cent and 14 per cent).

This study was designed to investigate the long-term effects of early pancreatic resection for acute necrotizing pancreatitis. During 1973–1978 40 resections were performed in our clinic. Eleven patients died initially (28 per cent). None of the four further deaths was due to pancreatitis or associated disorders. Twenty-four patients were reexamined 5–11 years after resection — one patient refused to participate. Five had not been able to return to work because of severe polyneuropathy; one more had retired because of chronic pancreatitis in the pancreatic remnant. Polyneuropathy was found in five further patients. The reason for this high incidence of polyneuropathy (42 per cent) remains unknown. Eight patients still drank excessive alcohol; three of them had had recurrent pancreatitis and dyspepsia, and insulin requiring diabetes. All but 2(92 per cent) had diabetes, 14 needing insulin - half of them at 6 months to 6 years after the resection. Moreover, 11 patients (46 per cent) suffered from dyspeptic symptoms. The results suggest that because of the high frequency of late complications, in addition to the early complications, early resection of pancreas should be critically re-evaluated as the treatment for acute necrotizing pancreatitis. If resection is used in patients with extreme pancreatic necrosis, careful and continuous postoperative follow-up will be needed.

The diagnosis of necrosis and its extent in acute necrotizing pancreatitis is one main problem in establishing criteria for possible pancreatectomy. With this in mind a clinicopathological analysis was carried out on 54 patients who had undergone pancreatic resection for acute necrotizing pancreatitis. The macroscopic appearance of the gland correlated poorly with its histology. Parenchymal necrosis varied from 0 to 100 per cent of the resected specimen though all the glands were considered totally or subtotally necrotic. In the clinicobiochemical status no criteria were found determining the extent of necrosis. Obesity, hypotension, hypocalcaemia and elevated serum creatinine in severely ill patients (as determined by Ranson criteria) strongly supported extensive peripancreatic and septal necrosis; however, 38 per cent of patients developed necrosis without those stigmata. While waiting for new methods to determine necrosis we prefer conservative treatment. In contrast to our previous tactics we think that resection should be limited to extreme cases in order to avoid resection of glands with limited necrosis and thus mainly reversible parenchymal damage.

The effect of an anti-cholinergic drug (atropine) on insulin secretion was studied in a double-blind manner by the glucagon C-peptide secretion test in five healthy subjects and controlled with saline only (placebo) in four subjects. Blood C-peptide increased only by 157% in the group given atropine and by 252% in the group given placebo. The blood glucose concentration increased by 25% and 32%, respectively. Thus, it is concluded that the cholinergic system, probably through the vagus nerve, has an insulin secretion stimulating effect. The results also suggest that denervation of the vagus nerve, e.g. in gastric surgery, may partly explain post-prandial hyperglycaemia particularly found in dumping.

Summary The amount of fibrinolytic activity in the thyroid gland equals that of the prostate. In order to examine the effect of the antifibrinolytic drug tranexemic acid on perioperative bleeding saline or tranexemic acid were given randomized double blind to 76 consecutive patients who came for scheduled thyroid surgery. No significant differences were found in perioperative bleeding between patients in the treatment group (n=39) and control group (n=37).

Twenty patients with ultrasonographic or computed tomographic diagnosis of pancreatic pseudocyst were referred for endoscopic retrograde cholangiopancreatography (ERCP). Two of these were found at laparotomy not to have pseudocysts and were excluded. Pancreatography was successful in 15 out of 18 cases (83%) and cholangiography in 12 out of 18 cases (67%). Three types of pseudocysts were noticed according to the communication of the pseudocyst to the main pancreatic duct and the presence of pancreatic duct stensosis. Successful treatment included two spontaneous resolutions, two internal drainages and three left pancreatic resections. In the eight percutaneous external drainages four recurrences (50%) occurred, one after closure of temporary pancreatocutaneous fistula. All the recurrences occurred in Type III pseudocysts with communication of the pseudocysts to stenotic main pancreatic duct. In these cases internal drainage would have been the preferable treatment method. We believe that by ERCP one can identify pseudocysts not suitable for external drainage.