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OBJECTIVES: Autologous arterio-venous (AV) fistulas seem to be superior to prothetic grafts in hemodialysis access surgery. We used an algorithm which enabled us to use autologous vein in over 99% of all fistula operations. DESIGN: All patients undergoing hemodialysis surgery during a three year period (n = 102) were enrolled in an open prospective observation study with the end points feasibility, perioperative complications and patency. MATERIALS: One hundred and two patients were followed until the end of the observation period (30/6/01). METHODS: All relevant data were recorded prospectively. The status of the individual fistula was recorded twice a year until the end of the observation period. Fistula-patency was calculated by life-table-analysis according to Kaplan-Meier. RESULTS: Except one patient presenting with a recurrent shunt aneurysm, no patient received prothetic material. At the end of the observation period all patients alive and under dialysis could use their autologous fistula. There was no perioperative mortality. One reoperation was required for a septic anastomotic rupture. Otherwise, only minor complications were observed. Cumulative 1-year and 3-year patency were 78.5 and 62.8% respectively for the Cimino and 75.2 and 66.8% for elbow fistulas. CONCLUSIONS: An autologous approach is nearly always possible. Besides fewer complications, the approach seems to be cost effective.

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BACKGROUND: The pre-operative differentiation of tumors of the pancreas, Papilla of Vater and the biliary tract is still unsatisfactory. Tumor marker analysis of the pancreatic juice did not improve the pre-operative diagnosis by a great deal. METHODS: Bile from resected gallbladders of patients suffering from carcinomas of the pancreato-biliary system was analysed for CA 19-9, CEA, CA 72-4, CA 125 and AFP concentrations. The results were compared to patients suffering from acute cholecystitis, cholecystolithiasis as well as those suffering from benign tumors of the pancreato-biliary region. RESULTS: Extreme high CA 19-9 concentrations were found in bile. Evaluations of the tumor-antigens CA 19-9, CA 72-4 and CEA in gallbladder bile were superior to any serum and pancreatic juice examination with respect to sensitivity and specificity. Observed sensitivities amounted to 100% for patients suffering from bile duct carcinoma (CA 19-9) and papillary carcinoma (CEA) at a specificity of 100%. CA 19-9 showed a sensitivity of 76.5% for pancreatic carcinomas at a specificity of 96.4%. CA 19-9 showed significant differences for the local tumor burden and for the degree of lymph node metastasis. Examination of tumor antigens in the gallbladder results in a high degree of discrimination for malignant and benign lesions of the subhepatic pancreato-biliary system. CONCLUSIONS: CA 19-9 must follow a entero-hepatic circulation, since it showed raised bile concentrations (factor: 10(4)) compared to serum analysis. Analysis of CA 19-9, CEA and CA 72-4 gives an opportunity for improvement in the detection of cancers of the pancreato-biliary system. Since the clinical important differentiation of tumors of the head of the pancreas (carcinoma vs. pancreatitis) remains unclear, an improvement by bile analyses must be assumed.

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BACKGROUND: An adenoma-carcinoma sequence also applies to adenomas of the major duodenal papilla. Therefore accurate preoperative diagnosis and tumor staging are essential to select the appropriate patients for adequate treatment. In a prospective, histopathologically controlled study of tumors of the main duodenal papilla, the preoperative diagnostic value of ultrasound (US) catheter probes applied during endoscopic retrograde cholangiopancreatography (ERCP) was investigated. METHODS: Intraductal US was compared with conventional endoscopic ultrasonography (EUS) and computed tomography (CT). In 27 consecutive patients with benign polypoid tumors of the major duodenal papilla (n = 12) and carcinomas of the papilla (n = 15), respectively, the value of these imaging procedures in determining tumor visualization, tumor diagnosis and tumor staging according to the TNM classification was assessed. Every patient underwent surgical resection; histopathologic evaluation of resected specimens served as the reference standard. RESULTS: Intraductal US was significantly superior to EUS and CT in terms of tumor visualization (100% vs 59.3% vs 29.6%, respectively). Sensitivity and specificity rates for intraductal US and EUS were 100% versus 62.5% and 75% versus 50%, respectively. Overall accuracy rate in tumor diagnosis for intraductal US (88.9%; 24 of 27) was significantly (p = 0.05) superior to EUS (56.3%; 9 of 16). The latter did not depict 4 adenomas and 7 carcinomas. Neither intraductal US nor EUS is suitable for detection of distant metastases. CONCLUSION: Intraductal US appears to be the most effective imaging method in visualizing, diagnosing and staging tumors of the major duodenal papilla. Combining ERCP with catheter probe sonography offers a new diagnostic modality that has some potential advantages for local staging of small tumors of the main duodenal papilla. Consequently, minimally invasive techniques for resection of seemingly benign tumors of the papilla or, even more so, of small carcinomas should preferably be based on intraductal US.

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This report describes the results of a phase II trial to evaluate the safety, feasibility and response of patients with irresectable, histologically proven, stage II-IV adenocarcinoma of the pancreas receiving high-dose octreotide treatment. Octreotide was self-administered subcutaneously (3 x 2000 micrograms per day) by 49 patients. Therapy was discontinued after progression of the disease. Due to the subseqment diagnosis of bile duct carcinoma and stage I disease, 2 patients were excluded, leaving 47 evaluable patients with measurable disease. The median Karnofsky score was 80%. 3 patients had stage II (6%), 19 stage III (40%), and 25 (53%) stage IV disease. Octreotide treatment resulted in stable disease in 9 patients (19%) for more than 12 weeks. No complete or partial response was observed. The median overall survival was 21.4 weeks and the median progression-free survival 9.0 weeks. Therapy with high-dose octreotide is feasible, well tolerated and might prolong survival. In a placebo-controlled phase III study the effects of octreotide in patients with pancreatic cancer will be confirmed.

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Acute pancreatitis is a multietiologic entity with rather diverse clinical courses. Whereas edematous pancreatitis has a mortality of less than 1%, nowadays; still approximately 20% of all patients with the necrotizing form succumb to the disease. To further improve therapeutic results a standardized approach should be used. For effective treatment the differentiation between edematous and necrotizing pancreatitis is crucial. All patients with signs of pancreatic necroses during abdominal ultrasound and patients with organ insufficiencies should undergo a CT-scan to define exactly the nature and the extent of the disease. Primarily all patients are treated conservatively. Main indications for operative intervention are signs for infection of pancreatic necroses and an acute abdomen due to local complications of acute pancreatitis. In cases of biliary origin an elective cholecystectomy has to be performed during a free interval to prevent a recurrence.

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The purpose of this preliminary study was to evaluate whether laser-induced interstitial thermotherapy (LITT) may be used for palliative treatment of localized hepatocellular carcinomas (HCC). We applied LITT to two patients suffering from unresectable localized hepatocellular carcinomas of different sizes (2.5 and 4 cm). LITT was performed with an Nd:YAG laser (1,064 nm) at 5 W laser power (15-20 minutes). Thermometry during LITT was performed by MRI using a temperature-sensitive T1-weighted fast low-angle shot (FLASH) sequence. Follow-up for local tumor control was performed by MRI and ultrasound. LITT was well tolerated and no adverse events occurred during or after LITT; no secondary liver lesions were seen in the follow-up (11 or 12 months, respectively). Only minimal tumor growth was observed in the larger HCC (from 4 to 5 cm), whereas the smaller HCC remained unchanged in size during 11 months of follow-up. We conclude that LITT might be an effective minimally invasive palliative treatment option for patients with small unresectable HCC.

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Local irresectable carcinoma of the pancreas was diagnosed by explorative laparotomy of a 62-years old patient. At this stage (T3 N1 M0), a curative surgical therapy was not possible. The prognosis in these cases is bad. Medium survival time is less than half a year. In order to improve prognosis a combined radiochemotherapy has been applied. The total tumor dose of 44.8 Gy was applied in 2 daily fractions of 1.6 Gy. On the first 3 days of radiotherapy 600 mg/m2 5-FU and 300 mg/m2 folinic acid were given i.v.. Chemotherapy was repeated each 28 days. After 45 months of observation and application of 20 courses chemotherapy no local or systemical progress can be proven in this patient. His health status is good. A combined radio-chemotherapy improves prognosis in locally irresectable carcinoma of the pancreas. In particular cases survival time is surprisingly long.

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The purpose of this study was to investigate whether MR angiography (MRA) of the portal venous system may be improved by means of superparamagnetic iron oxides (SPIOs) during accumulation phase imaging and to study the underlying contrast mechanisms. MRA of the portal venous system was performed on 48 patients before and after intravenous injection of a new SPIO (Resovist, Schering AG, Berlin, Germany). Resovist, as a predominantly liver parenchymal darkening agent on T2-weighted MR images with uptake into the reticuloendothelial cell system, was administered intravenously by bolus injection of 8 to 12 micromol Fe/kg body weight. Patients were scanned with breath-hold coronal and axial two-dimensional (2D) time of flight (TOF) MRA (TR = 31.0 msec, TE = 9.8 msec, flip angle (FA) = 50 degrees, and 6.9-second acquisition time per section) sequences. Signal intensity values of liver parenchyma, the portal venous system, and background were obtained for quantitative analysis. The clinical relevance of additional plain and contrast-enhanced MRA studies for surgical planning was assessed by independent reading of three readers. Liver signal-to-noise ratio (SNR) significantly decreased following iv injection of Resovist; however, SNR values of the portal veins or hepatic veins did not change significantly. Visibility of the portal venous system improved significantly (tertiary branches visible: pre in 15.2% versus post in 87.0% of patients). Resovist-enhanced 2D-TOF MRA may improve planning of liver resections by better demonstrating the relationship of central liver lesions and vessels on source images. The decrease in liver SNR at a constant vessel SNR after iv injection of Resovist improves MRA of the liver. SPIO-enhanced 2D-TOF MRA scans are superior to plain 2D-TOF MRA studies and may be added for the workup of preoperative patients.

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Between July 1990 and September 1993, 32 patients with locally advanced irresectable adenocarcinoma of the pancreas, histologically proven by laparotomy, were involved in our study. Patients were treated with hyperfractionated, accelerated radiotherapy and simultaneous application of 5-fluorouracil and folinic acid. Chemotherapy was given on days 1,2 and 3. Determination of the target volume for radiotherapy was carried out by computerized axial tomography. The total tumour dose of 44.8 Gy was applied relative to the 90% isodose in two daily fractions of 1.6 Gy, resulting in ten fractions per week. On the first three days of radiotherapy, 600 mg m-3 of 5-fluorouracil and 300 mg m-3 of folinic acid were given i.v. According to response, chemotherapy was repeated in 4-week intervals. The median survival time for all patients was 12.7 months, compared with 3-7 months after palliative surgery (historical control). The median progression-free interval was 6.6 months. Toxicity and therapy-induced morbidity were recorded according to WHO criteria. Nausea and vomiting of WHO grade I and II occurred in 72.1% and of grade III and IV in 27.9% of the patients. WHO grade I and II diarrhoea was seen in 11 patients. The overall incidence of leucopenia and thrombocytopenia was 37.4%; severe side-effects (WHO III-IV) occurred in 9.3% of all patients. One patient experienced a severe mucositis (WHO III). This combined modality treatment consisting of accelerated hyperfractionated radiotherapy and chemotherapy turned out to be feasible for patients with locally advanced, irresectable pancreatic cancer. The therapy could be applied in a short period of time, approximately half the time used in conventional therapy schemes.

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We report the case of a 66-year-old male who was admitted for obstructive jaundice presenting with an enlargement of the pancreatic head on CT scan. During exploratory laparotomy an invasion of the retropancreatic mesenteric vessels was found. Subsequently, the patient was included in a multi-center trial of subcutaneous high-dose octreotide in irresectable pancreatic cancer. After 6 months there was no tumour detectable on routine CT follow-up. One year after commencing octreotide treatment the patient underwent Whipple resection; the specimen showing a small T1N0M0 distal bile duct carcinoma. Taking into account that somatostatin receptors have been found on bile duct cancer cells our observation might warrant a controlled clinical trial.

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Endothelin evokes strong and longlasting constriction of postischemic sinusoids, leading to microcirculatory disturbances and local hypoxia, thereby causing liver damage. The aim of the study was to avoid the constrictive response of sinusoids by blocking endothelin receptors. In an in vivo ischemia-reperfusion model (21 female Wistar rats, 250-300 g) with portal decompression by a splenocaval shunt, hepatic ischemia was induced for 30 min by cross clamping of the hepatoduodenal ligament. The endothelin receptor antagonist bosentan (10 mg/kg bw IV) was administered before ischemia. The effect of the receptor antagonist was assessed by serum levels of aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) that were determined prior to ischemia, 2 and 6 h postoperatively. The local tissue pO2 was measured prior to inducing ischemia, 30 and 60 min after reperfusion. Application of 10 mg/kg bw endothelin receptor antagonist (ERA) intravenously did not influence the systemic blood pressure. The postischemic increase in serum ASAT and ALAT levels was diminished after receptor antagonist treatment (ASAT: p < .05). Local postischemic hepatic tissue pO2 was significantly decreased to 45% of basal values after 30 min and to 54.8% after 60 min of reperfusion (p < .05). Application of ERA results in a significant increase in local tissue pO2 to 110.9% of basal values after 30 min and to 90.7% after 60 min of reperfusion (p < .05). These data indicate that the endothelin receptor antagonist treatment results in a prevention of postischemic sinusoidal constriction avoiding hypoxia and leading to improved hepatocellular recovery.

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UNLABELLED: The purpose of this study was to assess the role of spiral computed tomography (SCT) and magnetic resonance imaging (MRI) in the preoperative work-up of patients with pancreatic carcinoma, regarding local resectability and vascular involvement. METHODS AND MATERIALS: A total of 28 patients (19 men and 9 women; mean age 58 years) with known or highly suspected carcinoma of the pancreas were included in this study. All patients prospectively underwent MRI ( +/- gadolinium-DTPA ) and SCT (3-phase examination) as preoperative diagnostic imaging studies, and laparotomy was carried out within 7 days, irrespective of the MRI or SCT findings. SCT and MR studies were reviewed independently by two radiologists, without knowing the results of the surgical exploration. Standardized image analysis was correlated with findings at laparatomy. RESULTS: Laparotomy identified 10 patients to be suitable for surgical resection and 18 pancreatic carcinomas to be unresectable. In 17 of 18 non-resectable carcinomas MRI and SCT were able to obtain correct information about unresectability (sensitivity 94%), in 7 (MRI), resp. 8 (SCT) carcinomas were correctly considered to be resectable (sensitivity 70% of MRI and 80% for SCT). The presence of vascular involvement was depicted by SCT with a sensitivity of 82-100% and 62-100% by MRI. The specificity varied between 85-100% for SCT and 77-100% for MRI. CONCLUSION: Both MRI and SCT are good techniques for the preoperative work-up of pancreatic carcinomas in order to obtain a correct assessment of local resectability.

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From 1990 to 1995, 27 patients with biliary injuries were treated at the Department of General Surgery of Münster University Hospitals. All lesions occurred during cholecystectomy, either via laparoscopy (n = 17) or via laparotomy (n = 10). Ten patients were male and 17 female. The mean age was 51.2 years. In all cases a preoperative ERCP was performed. Based on the ERCP status a new classification was developed taking into account the type and location of the injury, as well as the opportunity for endoscopic treatment. Twenty-two patients underwent surgical bile duct reconstructions (12 hepaticojejunostomies, 3 choledochojejunostomies, 7 direct reconstructions). In five cases endoscopic therapy alone was successful. The perioperative mortality was 7.4% (2/27). Three of the surviving 25 had to be readmitted for recurrent cholangitis. Only 15 feel well without any limitations on everyday activities.

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Postinterventional bleeding occurs in 2.5% after endoscopic sphincterotomy (EST). It is the most frequent complication of this technique. According to the world literature the mortality of post-EST-bleeding averages 10%. According to a review of the world literature patients are often operated upon too rarely and too late. Direct surgical interventions at the Vaterian papilla should be omitted because of the danger of post-operative pancreatitis. From our point of view laparotomy and ligation of the gastroduodenal artery are recommended if periampullary injection of epinephrine fails to control the bleeding. The cessation of the bleeding should be controlled by intraoperative endoscopy. During the same surgical intervention the underlying disease for EST, e.g. common bile duct stones, ought to be treated surgically to prevent a new bleeding episode. If the underlying disease was already cured or in case of inoperability, selective embolization of the gastroduodenal artery presents an alternative option.

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Despite certain advances, the overall prognosis for pancreatic carcinoma has remained extremely dismal. Even now, not more than 5% of all patients diagnosed as having pancreatic carcinoma survive 5 years. With this background, the standards and new developments for this entity are discussed.

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A randomized double-blind placebo-controlled multicentre trial was carried out in 247 patients undergoing major elective surgery for chronic pancreatitis to clarify whether the perioperative application of octreotide prevents postoperative complications. Eleven complications were defined, including death, anastomotic leakage, pancreatic fistula, abscess, fluid collection, shock, sepsis, bleeding, pulmonary insufficiency, renal insufficiency and postoperative pancreatitis. A total of 124 patients underwent pancreatic head resection, 55 left resection, 61 pancreaticojejunostomy and seven had other procedures. The overall mortality rate was 1.2 per cent (octreotide group 1.6 per cent, placebo group 0.8 per cent [corrected] (P not significant)). The postoperative complication rate in the octreotide group was 16.4 per cent (20 of 122 patients) and in the placebo group 29.6 per cent (37 of 125) (P < 0.007). The perioperative application of octreotide substantially reduces the risk of postoperative complications in patients undergoing major pancreatic surgery for chronic pancreatitis.

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Major pancreatic resection still carries a considerable risk for morbidity and even mortality. Complications occurring after pancreatic surgery are chiefly linked with exocrine pancreatic secretion. Therefore to inhibit exocrine pancreatic secretion perioperatively seems to be a promising concept in the prevention of complications following pancreatic resection. The hormone somatostatin and its synthetic analogue octreotide have been demonstrated to inhibit exocrine pancreatic secretion profoundly, particularly the secretion of proteases is decreased. In a randomized placebo-controlled multicentric and double-blind trial we analyzed the role of octreotide in the prevention of post-operative complications after major pancreatic surgery. A significant reduction of complications (fistula, abscess, fluid collection, sepsis, pulmonary insufficiency, postoperative acute pancreatitis) could be demonstrated in patients receiving octreotide (3 x 100 micrograms/day s.c.). The effect of octreotide was particularly true in patients undergoing a Whipple resection for cancer.

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OBJECTIVE: To find out if the presence of a stoma had any influence on the pathophysiology or prognosis of necrotising pancreatitis in rats. DESIGN: Randomised controlled study. MATERIAL: 112 male Wistar rats. INTERVENTIONS: Induction of pancreatitis by intraduodenal injection of 2 ml sodium taurocholate 2% with 10,000 units of trypsin; the duodenum and common bile duct were occluded for three minutes. The control group (n = 36) had no further procedure, but the remaining rats were randomised to have either caecostomy (n = 40) or colonic irrigation (n = 36). MAIN OUTCOME MEASURES: Mortality, histological grading of the pancreatitis, white cell count, serum amylase activity, and haemoglobin and endotoxin concentrations in blood. RESULTS: Operative mortality was 14% (n = 5) in the control group, 10% (n = 4) in the caecostomy group, and 8% (n = 3) in the irrigation group, leaving 31, 36, and 33 for assessment. Later mortality was 23% (n = 7), 17% (n = 6), and 9% (n = 3), respectively. The control group had a significantly higher median endotoxin concentration (219 ng/l) than both the caecostomy group (79.2 ng/l, p < 0.05) and the irrigation group (71.7 ng/l, p < 0.05). The amount of endotoxin was mirrored by the changes in the colonic mucosa in the different groups. CONCLUSION: Our results support the hypothesis that both caecostomy and colonic irrigation have a favourable effect on the outcome of necrotising pancreatitis in rats.

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With TPCD best results are gained with large diameter endoprostheses. In this instance special duodenoscopes with a working channel of 3.2 or 4.2 mm are needed for the implantation of 10 or 12 French endoprostheses. Alternatively, using the non-transendoscopic technique large diameter endoprostheses of 14 or more French can be implanted independently from the diameter of the working channel with conventional endoscopes. We have used this method developed at our institution in 1204 patients since 1982 and compared its results with 192 patients in whom the transendoscopic technique with 7-10 French endoprostheses was administered. The success-rate (non-transendoscopic technique 94 vs transendoscopic technique 79%), early complications (5 vs 11%), method-specific mortality (0.3 vs 1%), in-hospital mortality (3.6 vs 21%) and late complications (19 vs 33%) are clearly in favour of the non-transendoscopic approach. The higher rate of early complications and consecutively higher in-hospital mortality of the transendoscopic method with 7-10 French endoprostheses was mainly due to frequent episodes of early cholangitis due to insufficient biliary drainage. The higher success-rate of the non-transendoscopic approach is method specific ("Prothesenleger" guidable). A change of the endoscope is not necessary in contradiction to the transendoscopic method. Additional costs of special duodenoscopes that can be used neither for ERCP nor sphincterotomy are superfluous.(ABSTRACT TRUNCATED AT 250 WORDS)

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