F.A. Wenger

Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas : Results of 161 tumors in 126 patients

BackgroundLaparoscopic and retroperitoneoscopic excisions of pheochromocytomas and retroperitoneal paragangliomas are challenging surgical procedures because of extensive intraoperative catecholamine release, extreme vascularization, and demanding localization.MaterialsIn a prospective clinical study 161 chromaffine neoplasias (134 pheochromocytomas, 27 paragangliomas) were removed endoscopically in 126 patients (67 males, 59 females, age 41.7 ± 16.4 years; 130 operations). Six patients showed multiple (2–5) tumors. Tumor size ranged from 0.5 to 12 cm (mean 3.5 ± 1.9 cm). Forty-two patients suffered from hereditary diseases. Twenty-four patients had bilateral adrenal diseases; in 14 patients pheochromocytomas were removed on both sides synchroneously. Ten neoplasias were local or loco-regional recurrences (7 pheochromocytomas, 3 paragangliomas). The laparoscopic route was chosen in 16 operations; the retroperitoneoscopic technique was performed in 128 others. Partial adrenalectomies were performed in 57 operations (in all but one of the patients with bilateral disease). High-dosage α-blockade with phenoxybenzamine was routinely used.Results and DiscussionConversion to open surgery occurred once. Perioperative complications were minor (17%); mortality was zero. Operating time for unilateral retroperitoneoscopically removed primary pheochromocytomas (n = 113) was 82 ± 49 minutes (range: 20–300 minutes) and depended on tumor size (< 3 cm vs. ≥ 3 cm; P < 0.05) and gender (P < 0.001), but not on extent of resection (partial vs. total, P = 0.266). Operating time for paragangliomas ranged from 55 to 600 minutes. Median blood loss was 20 ml. Median duration of postoperative hospitalization was 4 days. In 22 of 24 patients with bilateral disease, complete preservation of cortical function was achieved. Locoregional and/or distant metastatic recurrence were found in 5 patients.ConclusionsEndoscopic removal of solitary, bilateral, multiple, and recurrent pheochromocytomas and retroperitoneal paragangliomas is feasible and safe, but surgeons need extensive experience in minimally invasive techniques, as well as in endocrine surgery.

Prospective Randomized Study Comparing Laparoscopic and Open Tension-free Inguinal Hernia Repair with Shouldice’s Operation

BACKGROUND Although tension-free techniques of hernia repair using synthetic meshes revealed encouraging results, the best method of inguinal hernia repair is still unclear. METHODS In a prospective randomized phase-II-B study, early postoperative results of laparoscopic transabdominal preperitoneal repair (n = 80), open plug and patch repair (n = 80), and Shouldices operation (n = 80) were compared. Postoperative pain and patients comfort were defined as main endpoints. RESULTS The laparoscopic approach had significantly longer operation time and was more expensive (61 +/- 12 minutes;

New Therapeutic Strategies to Avoid Intra- and Extraperitoneal Metastases during Laparoscopy: Results of a Tumor Model in the Rat

1,211) than plug and patch repair (36 +/- 14 minutes;

The Impact of Laparoscopy with Carbon Dioxide versus Helium on Immunologic Function and Tumor Growth in a Rat Model

124) and Shouldices operation (47 +/- 17 minutes;

Gastrointestinale Lebensqualität nach Duodenopankreatektomie beim Pankreascarcinom Vorläufige Ergebnisse einer prospektiv-randomisierten Studie: PD vs PPPD

69). Main postoperative complications were wound hematomas, seromas, and superficial wound infection, without significant difference between the groups. Postoperative pain, analgesia requirements, limitation of daily activities, and return to work did not differ between laparoscopic and open tension-free repair but were significantly lower in both groups compared with Shouldices operation. So far, no recurrence was observed after a mean follow-up of 25 months. CONCLUSION Open plug and patch repair is a promising technique of hernia repair in adults, because it offers the same excellent patient comfort as the laparoscopic repair but is less expensive and can be performed under local anesthesia.

Omega-3 fatty acid supplementation increases anti-inflammatory cytokines and attenuates systemic disease sequelae in experimental pancreatitis

Background: Therapeutic strategies to prevent port site recurrences in laparoscopy surgery of malignancies have not been investigated until now. Methods: The effects of taurolidine, heparin, and povidone iodine on the growth of rat and human colon adenocarcinoma as well as gallbladder carcinoma were investigated in vitro. Furthermore, cytokine release of growth-stimulating IL-1β by peritoneal macrophages was measured after incubation with carbon dioxide and additional incubation with the different agents. In the third experiment, prevention of intra- and extraperitoneal metastases by intraperitoneal instillation of the different agents during laparoscopy was investigated in a colon carcinoma model in the rat. Tumor cells were administered intraperitoneally in 100 rats, and pneumoperitoneum (8 mm Hg) was established over 30 min with carbon dioxide. Rats received either tumor cells, cells + heparin, cells + povidone iodine, cells + taurolidine, or cells + taurolidine + heparin. Results: In vitro, tumor cell growth decreased after incubation with taurolidine, taurolidine/heparin, and povidone iodine. Cytokine release was stimulated by incubation with carbon dioxide and could only be suppressed by incubation with taurolidine in vitro. In vivo, intraperitoneal tumor weight was lower in rats receiving heparin (251 ± 153 mg) and povidone iodine (134 ± 117 mg) compared to the control group (541 ± 291 mg), but even less when taurolidine (79 ± 82 mg) or taurolidine/heparin (18.3 ± 30 mg) were instilled. Conclusion: Heparin slightly inhibits intraperitoneal tumor growth in vivo, while povidone iodine and taurolidine cause a significant decrease in tumor cell growth in vitro as well as intraperitoneal tumor growth in vivo. Cytokine release of peritoneal macrophages is only suppressed by taurolidine. Total tumor take and trocar metastases are only suppressed by taurolidine and taurolidine/heparin.

Prognosis Factors in Carcinoma of the Head of the Pancreas

Background: The pathogenesis of port site recurrences after laparoscopic surgery for malignant disease is still unknown. Whether different gases used to establish pneumoperitoneum have an influence on immunologic function and therefore on promotion of tumor growth has not yet been investigated. Methods: Tumor growth of colon adenocarcinoma DHD/K12/TRb was evaluated in a rat model after insufflation either with CO2 (n = 25) or helium (n = 25) and in a control group (n = 25). Tumor growth was measured subcutaneously and intraperitoneally 5 weeks after insufflation. Beside tumor growth, immunologic changes (peripheral leukocyte subpopulations, plasma levels of TNFα and IL-10) were evaluated during the perioperative course in all animals. Results: Subcutaneous tumor growth was promoted by the CO2 (99 ± 55 mg; p < 0.01) compared to the helium (40 ± 41 mg) and control groups (36 ± 33 mg). Total intraperitoneal tumor weight was 718 ± 690 mg in the CO2 group compared to the helium (549 ± 233 mg) and control groups (521 ± 221 mg). While peripheral leukocyte subpopulations only differed between the laparoscopic groups and the control group during the perioperative course, TNFα plasma levels were significantly decreased and IL-10 plasma levels significantly increased in the CO2 group compared to the helium and control groups in the postoperative course. Conclusion: The insufflation of CO2 promotes tumor growth compared to the helium and control groups in a rat model. In addition, increased tumor growth was associated with a significant increase in IL-10 and a decrease in TNFα plasma levels.

K-ras mutations in tissue and stool samples from patients with pancreatic cancer and chronic pancreatitis

BACKGROUND The Whipple operation (PD) is the standard operation in patients with cancer of the head of the pancreas and the periampullary region. However, the pylorus-preserving duodenopancreatectomy (PPPD) is supposed to be superior in gastrointestinal function. METHODS In a prospective randomized trial (October 1994-October 1998) PD and PPPD were compared in terms of global and gastrointestinal quality of life, operation time, duration of hospital stay, transfusions and perioperative morbidity. Quality of life was analyzed under standardized conditions (EORTC-QLQ-30) pre- and postoperatively (weeks 2, 6, 12, 24, 36, 48, and 60). RESULTS A duodenopancreatectomy was performed in 48 patients because of cancer of the head of the pancreas (n = 38) and the periampullary region (n = 10) (PD, n = 24; PPPD, n = 24). The PD and PPPD groups did not differ according to age, gender or UICC stage. Operation time was shorter in the PPPD group (206 +/- 48 vs 306 +/- 54 min) (P < 0.05). Morbidity did not differ between the two groups (PPPD 20% vs PD 30%, P > 0.05). While there was no difference in global quality of life, gastrointestinal quality of life was postoperatively increased in the PPPD group regarding appetite, nausea and diarrhea (P < 0.05). While the preoperative body weight was reached after 6 months in 85% of the PPPD group (n = 20), this was true in only 60% of the PD-group (n = 14) (P < 0.05). CONCLUSION PPPD seems to be associated with a better postoperative gastrointestinal quality of life than PD.Summary.Background: The Whipple operation (PD) is the standard operation in patients with cancer of the head of the pancreas and the periampullary region. However, the pylorus-preserving duodenopancreatectomy (PPPD) is supposed to be superior in gastrointestinal function. Methods: In a prospective randomized trial (October 1994–October 1998) PD and PPPD were compared in terms of global and gastrointestinal quality of life, operation time, duration of hospital stay, transfusions and perioperative morbidity. Quality of life was analyzed under standardized conditions (EORTC-QLQ-30) pre- and postoperatively (weeks 2, 6, 12, 24, 36, 48, and 60). Results: A duodenopancreatectomy was performed in 48 patients because of cancer of the head of the pancreas (n = 38) and the periampullary region (n = 10) (PD, n = 24; PPPD, n = 24). The PD and PPPD groups did not differ according to age, gender or UICC stage. Operation time was shorter in the PPPD group (206 ± 48 vs 306 ± 54 min) (P < 0.05). Morbidity did not differ between the two groups (PPPD 20 % vs PD 30 %, P > 0.05). While there was no difference in global quality of life, gastrointestinal quality of life was postoperatively increased in the PPPD group regarding appetite, nausea and diarrhea (P < 0.05). While the preoperative body weight was reached after 6 months in 85 % of the PPPD group (n = 20), this was true in only 60 % of the PD-group (n = 14) (P < 0.05). Conclusion: PPPD seems to be associated with a better postoperative gastrointestinal quality of life than PD.Zusammenfassung.Hintergrund: Die kephale Pancreaticoduodenektomie nach Kausch-Whipple (PD) gilt als Standardverfahren bei der chirurgischen Therapie des Carcinoms des Pankreaskopfes und der periampullären Region, jedoch soll die pyloruserhaltende Resektion (PPPD) hinsichtlich der gastrointestinalen Funktion Vorteile bieten. Methodik: In einer prospektiv-randomisierten Studie (10/94–10/98) wurden beide Operationsverfahren verglichen. Hauptzielkriterium waren die globale und gastrointestinale Lebensqualität (LQ), Nebenzielkriterien waren die Dauer der Operation und des stationären Aufenthaltes, sowie der Verbrauch von Blutkonserven und die perioperative Morbidität. Die Lebensqualität wurde standardisiert mit Hilfe des EORTC-QLQ-30-Bogens präoperativ und in der 2., 6., 12., 24., 36., 48. und 60. postoperativen Woche erhoben. Ergebnisse: Bei 48 Patienten erfolgte wegen eines Carcinoms des Pankreaskopfes (n = 38) und der periampullären Region (n = 10) eine Duodenopankreatektomie (PD n = 24, PPPD n = 24). Beide Gruppen unterschieden sich nicht hinsichtlich Alter, Geschlecht und Tumorstadium. Die Operationsdauer der PPPD-Gruppe war signifikant kürzer (206 ± 48 vs 306 ± 54 min) (p < 0,05), die Morbiditätsrate beider Operations-Gruppen unterschied sich nicht signifikant (PPPD 20 % vs PD-Gruppe 30 %). Während die globale LQ beider Patientengruppen nahezu identisch war, zeigten sich signifikante Vorteile für die PPPD-Gruppe hinsichtlich der gastrointestinalen Parameter Appetitlosigkeit, Übelkeit und Erbrechen sowie Diarrhoe. In der PD-Gruppe erreichten nur 14 Patienten (60 %) ihr präoperatives Körpergewicht nach 6 Monaten gegenüber 20 Patienten (85 %) der PPPD-Gruppe (p < 0,05). Schlußfolgerung: Diese Ergebnisse deuten auf eine Verbesserung der postoperativen gastrointestinalen Lebensqualität in der PPPD-Gruppe gegenüber der PD-Gruppe hin.

Does Dietary α-Linolenic Acid Promote Liver Metastases in Pancreatic Carcinoma Initiated by BOP in Syrian Hamster?

BACKGROUND The cytokines involved in the systemic inflammatory response in acute pancreatitis (AP) comprise lipid mediators (eg, prostanoids, thromboxanes, leukotrienes) generated from arachidonic acid (AA) and eicosapentaenoic acid (EPA). The AA-derived mediators are generated from omega-6-fatty acid (FA) and have strong proinflammatory effects and the EPA-derived mediators generated from omega-3-fatty acid are less active or even exhibit anti-inflammatory effects. Basic parenteral nutrition delivers omega-6-FA and omega-3-FA at a ratio of approximately 7:1. AIM To investigate whether altering the FA composition by fish oil supplementation (omega-3-FA) affects cytokine production and the parameters reflecting systemic disease severity in experimental AP. METHODS Severe AP was induced in 30 rats by standardized intraductal infusion of bile salt and IV cerulein. Six hours after AP induction, rats were randomized to TPN using commercial solutions with identical amounts of glucose, amino acids, and fat but different FA compositions: group 1 received a soybean-based fat solution without additional fish oil and group 2 was supplemented with 0.2 g/kg per day fish oil. TPN was continued for 2 days. Serum concentrations of IL-6 and IL-10 were measured before and after AP induction and at 24 and 48 hours after starting TPN. Routine cardiorespiratory and renal parameters were monitored to assess the systemic response at the organ level. RESULTS Animals treated with fish oil had significantly higher IL-10 values (at 24 hours, 63 +/- 7 versus 46 +/- 3 pg/mL), produced more urine (28 +/- 0.9 versus 21 +/- 1.6 mL), and had significantly fewer episodes of respiratory dysfunction (defined as a pO2 < 80 mm Hg or pCO2 > 50 mm Hg for >15 minutes; 29% versus 67%) during the observation period. CONCLUSIONS Altering eicosanoid mediator precursor availability by infusion of (omega-3 fatty acid increases anti-inflammatory cytokines in this model of AP. This together with improved renal and respiratory function suggests that the systemic response to pancreatic injury is attenuated.

Tumor size and lymph-node status in pancreatic carcinoma — is there a correlation to the preoperative immune function?

Background: Due to a low survival rate even after a R0 resection of cancer of the head of the pancreas, a strict indication for a pancreaticoduodenectomy seems to be sensible. We have therefore analyzed our patients for possible prognosis factors. Methods: In a retrospective trial the courses of disease of all patients (1981–1996) with resected histologically proven carcinoma of the head of the pancreas were analyzed. The following patient-specific parameters were evaluated and examined in a single or multivariate analysis of prognosis factors: age, gender, tumor size (T status), lymph node involvement (N status), dimension of resection, operation method, time of operation, morbidity, clinic lethality and survival rate. Results: Between 1981 and 1996, 500 patients with ductal adenocarcinoma of the head of the pancreas were treated surgically. The rate of resection increased from 32.1% (1981–1986) to 37.8% (1991–1996) whereas the mortality rate decreased from 13.3 to 7.3%. The 5-year survival rate after resection was 11.8% with a median survival time of 13.8 months. In a multivariate analysis, only small tumors (T1, p < 0.016), the R0 status (p < 0.017) and the resection had a significant influence on the survival rate. Conclusion: Prognosis factors in the treatment of pancreatic cancer were tumor size (T1), tumor resection and R0 status.