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Competing Interests: Jan Borggrefe erhielt außerhalb dieses spezifischen Projekts Honorare von Philips Healthcare. N. Abdullayev und N. Große Hokamp erklären, dass kein Interessenkonflikt besteht

Pancreatic surgery has undergone significant progress during recent years. Specialised centres with interdisciplinary expertise have led to improved patient care with decreased morbidity and mortality. Regarding evidence-based medicine, consensus definitions on morbidity as well as high-quality studies, systematic reviews and meta-analyses on different topics of pancreatic surgery have been published. In acute pancreatitis paradigms have shifted towards conservative management, in chronic pancreatitis parenchyma-sparing resection techniques have widely become accepted. Management of cystic lesions - especially intraductal papillary mucinous neoplasms (IPMN) - has attracted great interest in surgical practice. In pancreatic cancer treatment not only surgical resection techniques have improved but also the central impact of adjuvant treatment has been demonstrated in large multicentre trials., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis., Material and Methods: Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis., Results: The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations., Conclusion: A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage., (Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: Ongoing debate continues regarding the appropriate management of pancreatic cysts (PCs). Disagreement prevails regarding frequency of needed follow-up, if and when to perform any PC needle biopsy and indications for surgical resection. EUS is increasingly used to help determine management of PCs., Methodology: One hundred and fifty seven consecutive patients with PCs were identified out of 5000 patients who underwent EUS between 1995-2007. In 2008, these patients were then prospectively provided clinical follow-up, and CEA, CA19-9 and CRP., Results: No symptoms could be definitively related to the PCs. Twenty four of 157 patients with suspected malignant cysts, mucinous cysts or IPMN had undergone surgical treatment. Whipple's operation was performed in 14 patients and distal pancreatectomy in 10 patients. Fifty PCs were located in the head of pancreas. In 89 patients prospective blood tests were performed; in 6 of them elevated levels of CA-19-9 were detected, 3 of these also had elevated serum CEA. Twelve patients had increased CRP values. No complication (requiring hospitalization) and no mortality related to EUS had occurred., Conclusions: Elements identified as important for assessment of PCs included: size, serum and fluid markers, imaging characteristics and clinical follow-up. These factors should be included in the recommended guidelines.

The aim of this report is to describe the clinical and pathological features of a lympoepithelial cyst of the pancreas and to recommend fine-needle aspiration biopsy for the differential diagnosis of this lesion. A 55-year-old man was incidentally diagnosed as having a pancreatic tumor by abdominal ultrasonography. A hypoechoic cystic lesion was detected on the surface of the pancreatic body. A computed tomography revealed a cystic lesion surrounded by a smooth, flat wall. Magnetic resonance imaging revealed that the lesion was a low-intensity mass on the T1-image and a slightly high-intensity mass on the T2-image. The lesion was diagnosed as a benign cystic tumor, and enucleation of the tumor was scheduled. The fine needle aspiration biopsy was performed after laparotomy, and cytology of the contents was negative for malignant cells. The postoperative pathological diagnosis was a lymphoepithelial cyst of the pancreas. This cyst is an unusual but benign mass that requires minimal surgery.

Laparoscopic surgery of the pancreas has been used for diagnostic but also for therapeutic purposes in increasing number. Case reports and multicenter studies summarizing the European and world wide experience have been published recently. The results show that laparoscopic surgery can be used for tumor staging of pancreatic cancer but also for the treatment of acute necrotizing pancreatitis and treatment of chronic pancreatitis, benign cystic lesions and solid tumors. In particular left sided pancreatic resection (90 % of the cases) is the preferred approach delivering good results. Recent studies show that the conversion rate is 14 % and mortality can be as low as 0 %. The reoperation rate is 6.3 % and the fistula formation is 17 % which is comparable to the results of open pancreatic surgery. The postoperative hospital stay seems to be limited to a mean of 7 days as compared to pancreatic surgery in the open abdomen. The laparoscopic Whipple resection with less than 3 % of the cases in the literature remains the exception.

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure has been performed more frequently. Three patients with intraductal papillary-mucinous tumor underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. In this procedure, the splenic vein is identified behind the pancreas and the connective tissue membrane is cut longitudinally above the splenic vein. An important point is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen. In one patient with intraductal papillary-mucinous tumor in the body of the pancreas who had undergone distal gastrectomy for duodenal ulcer 32 years previously, residual proximal gastrectomy could be avoided with this procedure. In this case, the histological diagnosis was a pseudocyst, and epithelial dysplasia was found in other pancreatic ductuli. In another case, epithelia were borderline between hyperplasia and adenoma. In both of these cases, the histological diagnosis was different from the preoperative diagnosis. Even with advances in imaging techniques, diagnosis of a cystic lesion of the pancreas is still very difficult. Ordinary distal pancreatectomy with splenectomy would have been oversurgery in these two cases, which could be avoided using our procedure. Severe complications were not found in any of the three cases and the postoperative course was uneventful. The patients have been followed as outpatients without any recurrence. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe, and should be performed for some patients with intraductal papillary mucinous tumor of the pancreas.

The authors report a case of a 26-year-old female who had a solid-pseudopapillary tumor of the pancreas. The patient had preoperative cyst fluid analysis that demonstrated low levels of carcinoembryonic antigen and moderate elevation in cyst fluid carbohydrate antigen 19-9 and lipase. Cyst fluid cytology was diagnostic. The tumor was successfully treated by complete enucleation.

A new case of congenital cyst of the pancreas is reported. A 34-year-old woman was admitted with a painless, large, epigastric mass. Ultrasonography revealed an anechogenic retrogastric tumor. Computed tomography scan described a liquid cyst of the pancreas which was 15 cm in diameter. During surgery, a well-delimited translucent cyst was found and no local malignancy was observed. Extensive distal pancreatic resection with preservation of the spleen was performed and a thin part of cephalic pancreas was preserved. The liquid of the cyst did not contain any mucus. Microscopic study of the cyst wall described normal cuboidal cells and congenital cyst of the pancreas was diagnosed. Several diagnoses including hydatid cyst, pseudocyst and cystic tumors of the pancreas are discussed. Before surgery, lack of acute pancreatitis in recent medical history rules out pseudocyst and hydatid cyst. During the operation, if cystadenocarcinoma is easily ruled out, macrocystic serous cystadenoma is more difficult to exclude. Only histological examination of the cystic wall confirms the difference between cystadenoma and congenital cyst which remains an exceptional entity.

We report on 3 children with a papillary cystic tumor of the pancreas. The patients presented with abdominal pain or a palpable tumor. All of them underwent complete tumor resection and spleen preservation was possible in 2 patients. Histologic examination showed a papillary cystic tumor of the pancreas. This tumor is characterized by a non-invasive growth pattern and metastasis is very rare. The boy described is the youngest male patient reported in the English literature. All patients are alive 6-51 months after diagnosis. Recognition of this entity is important because treatment differs from that of other pancreatic malignancies. Tumor resection without large safety margins is adequate for treatment. Therefore, preservation of pancreatic tissue and the spleen should be attempted in every child.

We hereby report the third case of antenatal diagnosis of congenital cyst of the pancreas. It is a very rare lesion and could present as a differential diagnosis of any intra-abdominal cystic mass. Early treatment is easy and prevents complications such as ascites and pancreatitis in case of intra-pancreatic enteric duplication.

A number of patients with chronic pancreatitis develop an inflammatory enlargement of the head of the pancreas leading to complications such as common bile duct, duodenal, pancreatic duct, and/or vascular obstruction. The duodenum preserving pancreatic head resection has been developed to treat these lesions and to avoid a Whipple procedure in chronic pancreatitis. Between 1972 and 1992 280 patients (231 male, 49 female, mean age 44, range 22-76 years) underwent a duodenum preserving pancreatic head resection for chronic pancreatitis. The indication to operate was a cholestases syndrome in 50% of the patients, a duodenal compression in 36% and an obstruction of the portal vein in 16% of the patients. 94% suffered from pain, 53% had recurrent severe pain attacks and 72% had daily pain. Hospital mortality was 1.1% (3/280). Pancreatic fistula, leakage of pancreatic anastomosis and postoperative bleeding occurred in 4.6%, 1.8% and 3.2% of the patients, respectively. A relaparotomy needed 16 patients (5.7%). With respect to glucose tolerance in the early postoperative period 88% of the patients, showed no change in comparison with the preoperative glucose tolerance analysis. In a long-term follow-up (mean follow-up time was 3.7 years (3 months to 18 years)) 219 patients were included. The late mortality within the follow-up period was 5.0% (11/219). 90% of the patients had no or rare pain in the long-term follow-up. 63% of the patients were full rehabilitated professionally. The duodenum preserving pancreatic head resection represents a new standard procedure which solves most surgical problems in chronic pancreatitis. It does not lead to diabetes mellitus.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors discuss the problems in the diagnosis and treatment of pancreatic pseudocysts; they emphasize the risk of complication. The authors discuss their personal experience in the treatment of 31 pancreatic pseudocysts using the different techniques, and the very good results they observed in their own series.

60 pancreatic pseudocysts are reported. 29 cystojejunostomies, 22 cystogastrostomies, 2 cystoduodenostomies and 7 external drainages were performed. Most favourable results could be recorded by cystojejunostomy. The total operative mortality was 8.3%, after cystojejunostomie 3.4%. Most dangerous complications were haemorrhage and peritonitis. In the follow up of internal operative drainage approximately 80% excellent or satisfactory results could be observed. Pancreatic pseudocysts lasting more than 6 weeks should be submit to surgical treatment. Cystojejunostomy is the most favourable procedure. External drainage is indicated in emergency or development of complications.

After duodenopancreatectomy the roentgenpattern of the upper gastrointestinal tract resembles the pattern after Billroth I- or Billroth II- resection. A different aspect results after Y-Roux anastomosis. The follow-up of pseudocysts drained into the stomach poses no problems. The follow-up of pseudocysts drained into the small bowel demands a roentgenexamination with duodenal intubation. The use of hypotonia is advisable in the diagnosis of malignancy. Problems may arise in roentgendiagnostics after palliative operations.

Percutaneous catheterised drainage of abscesses and pseudocysts as well as of circumscribed suppurations in soft-part tissue is considered an established therapeutic approach. Therapeutic puncture or drainage was successfully performed in 19 cases, following CT-targeted fine-needle puncture and subsequent cytological and bacteriological diagnosis. Inflammatory alterations were tackled by antibiotic therapy according to an antibiogram. Complications did not occur.

A report is presented on the results of the follow-up examination of 43 patients who had been previously operated on chronic pancreatitis. Clinical data such as the patients' well being, their ability to work were collected and specific tests for the function of the pancreas such as fat-content in faeces and glucose-tolerance-test were made. It was shown, that the pancreas-resected patients felt better in themselves. Moreover, their clinical picture was superior to that of non-resected patients although they had initially required a longer postoperative rehabilitation phase. Pseudocysts, which had been drained, showed no diminution of the pancreas function, nor any tendency to rest-pancreatitis.