R. Roscher

Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results.

In 128 patients with severe chronic pancreatitis and inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the pancreatic head was performed. Median postoperative hospitalization was 15.5 days, and the frequency of reoperation was 5.5%. One patient died during the early postoperative phase, and hospital mortality amounted to 0.8%. After a median follow-up period of 3.6 years (range of 7 months to 16 years), six of 127 patients died (late mortality of 4.7%). Seventyseven per cent of the patients were completely free of abdominal pain, 67% returned to their former occupations. During the late follow-up period, the glucose metabolism was unchanged in 80.7% of the patients, in 13.7% it deteriorated, and in 5.5% it improved permanently; 80% of the patients experienced a marked increase in weight averaging 8.7 kg. Compared with the Whipple procedure, the duodenum-preserving resection of the head of the pancreas spares the patient with chronic pancreatitis a gastrectomy, duodenectomy, and resection of the extrahepatic biliary ducts. In terms of a subtotal resection, the limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the low early and late postoperative morbidity and mortality.

Glucose homeostasis and endocrine pancreatic function in patients with chronic pancreatitis before and after surgical therapy

In a prospective clinical-experimental study, 15 consecutive patients with chronic pancreatitis, operated on because of severe pain, were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th day postoperatively, and 3 months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, and pancreatic polypeptide were determined. As indicated by the k value, glucose tolerance improved postoperatively in 10 patients (66.6%); three patients (19.9%) showed no change, and one patient (6.6%) was worse. Only one patient (6.6%) developed evident diabetes mellitus immediately postoperatively. Pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (p < 0.01). The stimulation of pancreatic polypeptide after oral glucose was significantly lower postoperatively (p < 0.01). Duodenum-preserving pancreas head resection does not lead to an impairment of glucose tolerance in the majority of patients; a deterioration was observed only in few cases (13.3%).

High sensitivity and specificity of CA 19-9 for pancreatic carcinoma in comparison to chronic pancreatitis: serological and immunohistochemical findings

The serum carbohydrate antigenic determinant (CA 19–9) was assayed in patients with various diseases (87 patients with pancreatic carcinoma, 747 patients with benign diseases, and 547 patients with extrapancreatic malignant growths) and it proved to be particularly sensitive for adenocarcinoma of the pancreas (80 of 87,92%) as compared to only 14% in the group of patients with benign diseases. Twenty-seven percent of the patients with chronic pancreatitis and 28% of the patients with acute pancreatitis showed elevated CA 19–9 concentrations of more than the upper normal value of 37 U/ml. In 38% and 32% of our cases with carcinoma of the stomach and colorectal carcinoma, respectively, CA 19–9 was estimated as being above the normal range. The preoperatively raised CA 19–9 concentration in patients with pancreatic carcinoma decreases after curative resection of the carcinoma to values within the normal range. However, in no CA 19–9 estimation following a palliative surgical intervention or in cases of inoperable carcinomas a serum concentration of less than 37 U/ml was recorded. In immunohistochemical specimens we found a difference between CA 19–9 antigen concentrations on the cell surface and secretion in pancreatic carcinoma and chronic pancreatitis.

Bacterial microflora, endogenous endotoxin, and prostaglandins in small bowel obstruction

The objective of this experimental study of small bowel obstruction was to investigate luminal bacterial colonization and assess the most likely mediator substances responsible for the pathophysiologic alterations, those being endogenous endotoxin and prostaglandins. Eighteen pigs with small bowel obstruction and 11 sham-operated control animals given constant infusion therapy were investigated over 7 days. Bacteria determinations were performed at operation and at sacrifice. Endotoxin levels were determined three times and prostaglandin levels, twice daily in portal and central venous blood. In the pigs with small bowel obstruction, greatly increased microflora with a predominance of E. coli bacteria was observed in the obstructed bowel. Endotoxin measurements proved general release into the circulation, with potentially toxic levels in the systemic circulation arising relatively late on the fourth postobstruction day. Beginning on the first postobstruction day, stimulation of the prostaglandin system occurred which was initially limited to the gastrointestinal tract but spread systemically when the obstruction persisted for more than 5 days. Vasoactive eicosanoids were predominantly involved. The control animals showed none of the alterations seen in the animals with small bowel obstruction.

The Value of CA 19-9 in Gastric and Colorectal Carcinoma

We have conducted a prospective study of 441 patients, to investigate the utility of a new tumor marker CA 19-9 for the diagnosis and monitoring of patients with cancer of the gastrointestinal tract (93 patients with colorectal carcinoma, 57 with carcinoma of the stomach, 10 with esophageal carcinoma, 45 with malignancies outside the gastrointestinal tract, and 236 with benign general surgical disease). Results were compared to those obtained for carcinoembryonic antigen (CEA) in the diagnosis of carcinoma of the stomach and colon/rectum. CEA is more sensitive than CA 19-9 in all stages of carcinoma of the stomach and colon/rectum. During treatments of gastrointestinal carcinomas, CEA and CA 19-9 were determined at the same time in 66 and 165 patients with surgically treated carcinoma of the stomach and colorectal carcinoma, respectively. It was noted that CEA is more sensitive than CA 19-9 in detecting recurrence. However, CA 19-9 is more specific. The best results were obtained when both markers were used together.

Regional Chemotherapy in Liver Metastases of Colorectal Carcinoma: Monitoring with Arterial Computed Tomography

Continuous chemotherapy was administered to 82 patients through the hepatic artery via Infusaid pumps. In order to obtain a primary status and to evaluate the success of therapy, the perfusion patterns of the liver and of the existing tumor masses in the liver were estimated by conducting arterial angiocomputed tomographies (AACTs) immediately after pump implantation of every 3 months thereafter. In 70% of the patients, findings showed both liver lobes to be homogeneously perfused, 24% demonstrated distinct inhomogeneities. The response of the latter cases should depend primarily on the efficacy of the administered cytostatic agent. Six percent of the patients showed selective perfusion of either the left or right hepatic lobe. In these cases, only the perfused liver regions exhibited stable disease or regression of the metastases, whereas the metastases of the nonperfused regions progressed. At 3-month follow-up, the majority of the patients (50-57%) showed homogeneous hepatic perfusion. Inhomogeneities were found in 26-36% of the patients, 12 patients demonstrated incomplete perfusion. There was no association between the perfusion patterns of the metastases or of the prechemotherapeutic liver involvement and the response of the metastases to regional chemotherapy. In regional chemotherapy, liver perfusion should be controlled both intraoperatively or directly postoperatively and during therapy.

The clinical relevance of tumor marker CEA, CA 19-9 in regional chemotherapy of hepatic metastases of colorectal carcinoma.

Up to December 1986, 50 patients with documented hepatic metastases from colorectal carcinoma were treated with 5-fluoro-2-deoxyuridine (FUDR) using Infusaid pumps. The response of liver metastases to regional chemotherapy was studied by computerized tomography (CT) and carcino-embryonal antigen (CEA), and/or CA 19-9 antigen serum assays. Preoperative CEA values were pathological in 94% of the patients but only 48% had a pathological concentration of the antigen CA 19-9 of over 37 U/ml. The course of CEA and CA 19-9 in combination with the arterial angio-CT reflected the response of liver metastases to regional chemotherapy. A decrease or normalisation of CEA and CA 19-9 after the beginning of therapy is an indication of partial or complete remission of metastases (68% of the patients showed lowered CEA serum values). If the marker continues to rise in serum this is a danger signal of progression of liver metastases or of extrahepatic tumor spread if the tumor stage in the liver remains unchanged.

161. Bakterielle Kontamination der Pankreasnekrose bei nekrotisierender Pankreatitis — Der verlaufsbestimmende Parameter

SummarySeptic complications are the most common causes of death in necrotizing pancreatitis. In 134 patients, necrotic material obtained at surgery was investigated bacteriologically: 55 patients were contaminated (41 %) by gram-negative germs in 71 % of the cases. Lethality in the contaminated group was 33% in contrast to 10% in the sterile patients (p < 0.01). The operative procedure consisted of necrosectomy and postoperative abdominal lavation. The course of necrotizing pancreatitis with respect to morbidity and mortality is clearly determinated by bacterial contamination, especially in cases of early infection within 14 days after the onset of the disease.ZusammenfassungSeptische Komplikationen sind die häufigste Todesursache bei akuter Pankreatitis. Bei 134 Patienten wurde intraoperativ ein Abstrich von der Pankreasnekrose entnommen. 55 Patienten (41%) waren kontaminiert mit überwiegend gramnegativen Keimen. Die Letalität der hakterienpositiven Patienten betrug 33% gegenüber 10% in der bakteriennegativen Gruppe (p < 0,01) bei gleichartigem Therapieverfahren (Nekrotektomie und Lavage). Der Verlauf der nekrotisierenden Pankreatitis hinsichtlich Morbidität und Sterblichkeit wird eindeutig determiniert durch die bakterielle Kontamination vor allem, wenn eine Frühkontamination innerhalb 14 Tagen nach Beginn der Erkrankung erfolgt.

Regional Chemotherapy in Hepatic Metastases of Colorectal Carcinoma: Continuous Intra-arterial Versus Continuous Intra-arterial/Intravenous Therapy

About 25% of patients have already liver metastases when the diagnosis of colorectal carcinoma is established. In another 30%–40% of the patients, metachronic metastases of a primary tumor settle in the liver, indicating that liver metastases are a significant factor for the prognosis of colorectal carcinoma [1]. The median survival time of the patients is approximately 6 months; only 7% live longer than 1 year [3]. Lymphogenous spread of metastases is not the decisive factor; rather, it is the invasion of the primary tumor into the vascular system [4].

The value of CEA and/or CA 19-9 serum course in the regional chemotherapy of liver metastases from colorectal carcinoma

The response of metastases of the liver to regional chemotherapy (RC) depends on the following: I. effect of the cytostatic agents used; 2. sufficient perfusion of the cytostatic agent in the liver, especially at the site of the metastases. In order to assess the perfusion pattern of the liver after the inplantation of the infusaid pump and its changes during the treatment, we carried out an AACT in 34 pts. inmediately after the i~plantation of the pur~p and in 3 ~nths intervalls thereafter; each time O. 3 ml/sec, of contrast medium (CM) were infused continuously via the side-port. In 31 patients the placing of the catheter was carried out via the A.gastro-duodenalis, in I patient via the A.lienalis into the A.hepatica, and in 2 pts. via the A.hepatica d~a and sinistra. Results: Primary AACT n=34 (homogenous perfusion of both liver lobes (LL) n=22; one LL more perfused than the other one n=9 ; perfusion of one LL only n=3. The control AACT in 3 months intervals showed a change of the initially homogenous perfusion of the liver in 6 pts. The liver was still perfused, but the concentrations of CM in the right and left LL were different. In 3 pts. with initially homogenous liver perfusion no more perfusion of the left LL couls be detected during the treatment; obviously a left-sided spread of metastases occurred, while a partial regression or stable disease was to be seen on the right. This is probably caused by a blockage of the A.hepatica sinistra, due to intrahepatic progressive metastases. A regular check-up of the parfusion is of utmost importance. Regional chemotherapy is inadequate when incomplete perfusion of the liver occurs in the course of treatnent. Then it should be supplemented by systemic therapy.