J.M. Läuffer

Intrapancreatic accessory spleen. A rare cause of a pancreatic mass.

SummaryConclusion: The clinical significance of intrapancreatic accessory spleens resides in the mimicry of pancreatic cancer. Radionuclide tests (Octreotide scan and Tc99m sulfur colloid scan) should be undertaken to distinguish these lesions from neuroendocrine tumors, hypervascular metastases and pancreatic carcinoma. If the tests are equivocal, diagnostic laparotomy or laparoscopy is recommended.Background: Despite its relatively common occurrence, intrapancreatic ectopic splenic tissue is rarely deted owing to its asymptomatic nature.Methods: We report a case of a clinically asymptomatic patient in which abdominal computed tomography (CT) scans revealed a mass of 1.5 cm in diameter in the distal pancreas. The tumor markers CA 19-9 and carcinomebryonic antigen (CEA) were slightly elevated, and pancreatic neoplasm was suspected.Results: Left pancreatic resection and splenectomy were performed. The removed specimen disclosed the presence of an accessory spleen within the pancreatic tail.

Celiac Axis Infusion Chemotherapy in Advanced Nonresectable Pancreatic Cancer

SummaryConclusionBased on these data we suggest that regional intra-arterial chemotherapy for advanced pancreatic cancer seems not to be superior to common treatment modalities, such as combined radiochemotherapy.BackgroundThe prognosis for advanced pancreatic cancer is very poor. No standard treatment is available. Recently, better survival and quality of life was reported from regional cancer treatment via celiac axis infusion. In an attempt to confirm these results we conducted a phase II study of intra-arterial chemotherapy for nonresectable pancreatic cancer.MethodsFrom May 1994 to February 1995, 12 consecutive patients with biopsy-proven advanced ductal carcinoma of the exocrine pancreas were given intra-arterial infusions consisting of Mitoxantrone, 5-FU+ folinic acid, and Cisplatin via a transfemorally placed catheter in the celiac axis. Six patients were classified as UICC stage III and six as stage IV with the liver as the sole site of distant metastasis. Nine patients had primary and three had recurrent pancreatic carcinoma after a Whipple procedure. Nonresectability of primary tumors was assessed in all patients by laparotomy or laparoscopy.ResultsA total of 31 cycles of chemotherapy (mean 2.6 cycles/patient) was administered. Catheter placement was technically feasible in all cycles. A groin hematoma was the only catheter complication. The follow-up by CT sans at 2-mo intervals revealed partial remission in 1 patient (8%), temporary stable disease in 4 patients (33%), and disease progression in 7 patients (58%). The same response was obtained after analyzing the CA 19-9 course. Median survival in stage III patients was 8.5 mo (3–12 mo) and in stage IV patients 5 mo (2–11 mo). Toxicity according to WHO criteria consisted of grade III (4 events), grade II (10 events), and grade I (17 events), mainly resulting from leucopenia and diarrhea/vomiting. Nine of 11 patients experienced temporary relief of pain immediately after regional treatment.

Case Report: Adenomyoma of the Distal Common Bile Duct Mimicking Cholangiocarcinoma

Benign tumors of the extrahepatic biliary tract are exceedingly rare pathological ® ndings but are of clinical importance because of the differential diagnosis of the more common carcinoma of the bile ducts. Growing locally, they may be classi® ed in one of the following histopathological entitie s: (1) polyps, ade nomas, adenomatous papillomas, and multiple biliary papillomatosis ; (2) adenomyosis; (3) granular cell myoblastomas; (4) neural tumors; (5) le iomyomas, and (6) various other entities such as pseudotumors, in ̄ ammatory masses, and heterotopic tissue . The most common benign bile duct tumors are those arising from the glandular epithe lium lining the ducts. Approximate ly two thirds of the reported cases were adenomas, adenomatous papillomas, or multiple biliary papillomatosis. Adenomyoma is a rare clinical condition. It is a well-known lesion in the fundus of the gallbladde r (1), but only 10 cases in the extrahe patic biliary tract have been described in the world literature so far. According to Burhans and Myers, they have been reported in only 0.1% of all biliary tract operations and constitute 0.6% of all extrahe patic bile duct neoplasms (2). We describe a patient in whom a hemisphe rical mass in the terminal portion of the common bile duct was detected incidentally by intraope rative cholangiography performed during laparoscopic chole cystectomy. Local excision was successfully carried out and histology revealed the diagnosis of adenomyoma. In the following report, a review of the world literature is presented, and the clinical, diagnostic, histological, and surgical relevance will be discussed.

Radikale onkologische Chirurgie als Therapieprinzip beim Pankreaskarzinom

ZusammenfassungGrundlagen: Mit den heutigen tiefen Morbiditäts-und Mortalitätsraten für Pankreasresektionen ist die Indikationsstellung für eine Standard- oder pyloruserhaltende Whipple-Operation weniger restriktiv zu stellen.Methodik: Pankreasresektionen für Karzinome sollten deshalb in kurativer oder palliativer Absicht, wenn immer möglich, durchgeführt werden. Verlangt werden dafür erfahrene Chirurgen mit über 10 Pankreaseingriffen pro Jahr und einer Mortalität von unter 10%. Als Standard gilt eine 2reihige Pankreatikojejunostomie mit Y-Roux-Rekonstruktion sowie die peri- und postoperative Therapie mit Octreotid während 7 Tagen.Ergebnisse: Innerhalb von 32 Monaten wurden 113 Patienten mit Pankreaskarzinom behandelt. Die Resektionsrate lag bei 50%, bei der Mehrzahl der Fälle wurde eine pyloruserhaltende Whipple-Operation durchgeführt (30/57). Die postoperative Morbidität lag bei 22,3%, kein Patient verstarb.Schlußfolgerungen: Die erweiterte (radikale) Duodenopankreatektomie wird ihren Wert im Vergleich zur Standard- oder pyloruserhaltenden Duodenopankreatektomie in prospektivrandomisierten Studien erst noch belegen müssen. Die Wirksamkeit einer adjuvanten Chemo- und/oder Radiotherapie bedarf weiterer Überprüfung mittels prospektiver Studien.SummaryBackground: The classical and pylorus-preserving Whipple procedure in patients with pancreatic carcinoma can be performed safely with low morbidity and mortality. Therefore, the indication for surgical intervention should be indicated with less restrictions.Methods: It has been shown that even a palliative resectional procedure has advantages for the patients. Prerequisite to experienced surgeons should be 10 pancreatic resections per year and a mortality < 10%. In order to reduce postoperative typical complications after pancreatic resections in the perioperative period beside antibiotics Octreotid has to be given to inhibit exocrine pancreatic secretion.Results: Within 32 months 113 patients with pancreatic cancer were treated at out hospital. Resection rate was 50% (57/113), in the majority of patients a pylorus-preserving whipple procedure was performed (30/57). Postoperative morbidity was 22.3%, no patient died.Conclusions: The value of extensive and radical pancreatoduodenectomy and the reconstruction according to classical and the pylorus-preserving procedure as well as the role of adjuvant or neoadjuvant chemo- and/or radiotherapy have to be proven in randomized controlled trials. Pancreatic cancer is still a challenging disease for researchers to improve patient’s prognosis.

Endoscopic Management of latrogenic Biliary Fistulas

Although biliary fistulas may represent a complication of long-standing biliary tract calculous disease, they more commonly develop as a result of complicated cholecystectomy, a retained common bile duct stone, surgical trauma to the extrahepatic duct, or as a consequence to local infection. In the past, biliary fistulas represented a difficult clinical problem with high morbidity and mortality rates due to operative repair. Recently, different methods of nonsurgical alternatives have been proposed. We report 3 consecutive cases in which postoperative biliary fistulas were treated successfully by an endoscopically placed nasobiliary tube or an endoprosthesis. These methods can be used safely and effectively and are a good alternative to operative treatment.