Practice guidelines in acute pancreatitis.

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Role of WHO.

The orderly migration of various white blood cell types to inflammatory sites is a highly regulated process that involves a diversity of adhesion and signaling molecules. This cellular influx is initiated by relatively low affinity interactions that allow for leukocytes to roll along the vascular surfa ce. This rolling phe­ nomenon is mediated by adhesive interactions between lectin containing ad­ hesion molecules, termed selectins, on both the vascular endothelium and leukocytes, and car bohydrate ligands immobilized on mucin-like scaffolds. This adhesion allows for a rapid recognition of various cell types under the conditions of vascular flow, with the result that inflammatory cells are spe­

Interactions and the initiation of the inflammatory response

Pancreatic cancer has a dismal prognosis because cancer-specific symptoms occur only at an advanced stage. If the cancer is to be discovered early, screening will need to be done in asymptomatic individuals. Because the incidence of pancreatic cancer is low, screening for asymptomatic cancer in the general population is not feasible; therefore, screening will need to be restricted to people at high risk of this disease. The proportion of patients with pancreatic cancer who also have hyperglycaemia or diabetes has previously been under appreciated. New data show that up to 80% of patients are either hyperglycaemic or diabetic, both of which can be detected in the presymptomatic phase. Diabetes has been shown to improve after pancreatic-cancer resection, suggesting that diabetes is caused by the cancer. Conversely, older patients with new-onset diabetes have about an eight-times higher risk of having pancreatic cancer than the general population. Recognition of new-onset diabetes as an early manifestation of pancreatic cancer could lead to the diagnosis of asymptomatic, early-stage pancreatic cancer. However, primary type-2 diabetes is common in the general population and pancreatic cancer is relatively uncommon, and the two forms of diabetes are clinically indistinguishable. The success of a strategy using new-onset hyperglycaemia and diabetes as a screening tool to identify people with a high likelihood of having asymptomatic pancreatic cancer will depend largely on our ability to differentiate pancreatic-cancer-associated diabetes from the more common type-2 diabetes by use of a (serological) biomarker.

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New-onset diabetes: a potential clue to the early diagnosis of pancreatic cancer

Objective The aim of this study was designed to determine whether the period of drain insertion influences the incidence of postoperative complications. Background data The significance of prophylactic drains after pancreatic head resection is still controversial. No report discusses the association of the period of drain insertion and postoperative complications. Methods A total of 104 consecutive patients who underwent pancreatic head resection were enrolled in this study. To assess the value of prophylactic drains, we prospectively assigned the patients into 2 groups: group I underwent resection from January 2000 to January 2002 (n = 52, drain to be removed on postoperative day 8); group II underwent resection from February 2002 to December 2004 (n = 52, drain to be removed on postoperative day 4). Postoperative complications in the 2 groups were compared. Results The rate of pancreatic fistula was significantly lower in group II (3.6%) than in group I (23%) (P = 0.0038). The rate of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, was significantly reduced in group II (7.7%) compared with group I (38%) (P = 0.0003). Eighteen of 52 (34.6%) patients in group I had an inserted drain beyond 8 days, whereas only 2 of 52 (3.7%) patients in group II had an inserted drain beyond 4 days (P = 0.0002). Cultures of drainage fluid were positive in 16 of 52 (30.8%) patients in group I, and in 2 of 52 (3.7%) patients in group II (P = 0.0002). Intraoperative bleeding (> 1500 mL), operative time (> 420 minutes, and the period of drain insertion were significant risk factors for intra-abdominal infections (P = 0.043, 0.025, 0.0003, respectively). The period of drain insertion was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio, 6.7). Conclusion Drain removal on postoperative day 4 was shown to be an independent factor in reducing the incidence of complications with pancreatic head resection, including intra-abdominal infections.

Early Removal of Prophylactic Drains Reduces the Risk of Intra-abdominal Infections in Patients With Pancreatic Head Resection: Prospective Study for 104 Consecutive Patients

https://www.annalsthoracicsurgery.org/article/S0003-4975(05)01559-6/pdf

Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents.

Background Postoperative morbidity is high after pancreatic head resections. Data about risk factors are controversial. The aim of this study was to evaluate risk factors for complications after pancreatic head resection and to assess whether the complication rate changed during the study period. Methods Data of 301 patients undergoing pancreatic head resection were recorded prospectively. Risk factors were assessed by multivariate analysis. The first and second part of the study period were compared. Results Mortality was 3%. Overall and surgery-related complications occurred in 42% and 28%, respectively. Independent risk factors for postoperative morbidity were impaired renal function (odds ratio [OR] 2.7), absence of preoperative biliary drainage (OR 1.9), and resection of other organs (OR 3.2). Complication rate, duration of surgery, amount of blood transfused, and length of hospital stay decreased during the study period. Conclusions Increasing hospital experience decreased complication rates. Patients with risk factors should be considered for transferal to specialized centers.

Risk factors for complications after pancreatic head resection

Background Graft pancreatitis is thought to be induced by ischemia/reperfusion. Animal experiments have suggested that an impaired microcirculation is crucial in this process. We have therefore studied the relevance of microcirculation in clinical pancreas transplantation. Methods. In 17 patients undergoing pancreas transplantation, tissue pO 2 was monitored continuously by an electrode implanted into the pancreatic tail. A catheter was inserted in the distal part of the splenic vein of the pancreas graft. After reperfusion blood samples were taken from this catheter and blood flow was measured by the venous outflow method. The degree of graft pancreatitis was assessed by peak-C-reactive protein (CRP) defined as highest CRP within 3 days after transplantation. Results. Tissue pO 2 increased within 5 min after reperfusion. Thereafter, in most patients a transient decrease was noted, indicating impairment of nutritive perfusion. During this period there was an increasing negative correlation between peak-CRP and tissue pO 2 which was highly significant at 60 min after reperfusion (r=-0.70, P<0.002). Also donor age correlated significantly with peak-CRP (r=0.64, P<0.005) and to a somewhat lesser extend with tissue pO 2 60 min after reperfusion (r=-0.55, P<0.03). Conclusion. These data show that the degree of organ damage in clinical pancreas transplantation is directly related to an impairment of microcirculation in the early reperfusion period. These data also support the idea that grafts from older donors have a higher probability to develop graft pancreatitis and that this might be due to an increased incidence of microcirculatory disturbances in these organs.

Impairment of microcirculation in the early reperfusion period predicts the degree of graft pancreatitis in clinical pancreas transplantation.

Background The objective of this study was to determine the long-term results after simultaneous pancreas-kidney transplantation (SPK) at a single-center institution in Europe. Patients and methods Seventy-eight consecutive patients with insulin-dependent diabetes mellitus and end-stage nephropathy were followed for a median of 7 years after SPK. Immunosuppressive protocol consisted of cyclosporine A, azathioprine, prednisone, and antithymocyte globulin. Multivariate Cox proportional hazard model was used to investigate the impact of different putative risk factors on long-term patient survival. Health-related quality of life was assessed by a validated questionnaire (SF-36). Results Patient survival at 5 and 10 years was 81% and 67%, respectively. Pancreas function rate was 73% and 60% and kidney function 67% and 44%, respectively. In multivariate analysis, preexisting myocardial infarction (relative risk [RR] 5.1, 95% confidence interval [CI] 1.5-16.6) and amputation (RR 3.7, 95% CI 1.1-12.9) were strongly associated with a diminished long-term patient survival. Analysis of patients with long-term functioning pancreas and kidney grafts revealed excellent results for quality of life posttransplant that were comparable with average scores of the normal German population. Conclusions This series representing the largest experience with long-term follow-up in Europe confirms an excellent long-term survival and an exceptional quality of life after SPK.

Long-term follow-up of 78 simultaneous pancreas-kidney transplants at a single-center institution in Europe.

Objectives:Impairment of glucose tolerance is one of the leading clinical presentations in patients with pancreatic carcinoma. The mechanism of disturbed glucose metabolism, however, is still under debate. Using microarray technology, key mechanisms of deregulated molecular functions of cancer cell–

Stefan Benz

Papers

Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents.

Risk factors for complications after pancreatic head resection

Impairment of microcirculation in the early reperfusion period predicts the degree of graft pancreatitis in clinical pancreas transplantation.

Long-term follow-up of 78 simultaneous pancreas-kidney transplants at a single-center institution in Europe.

Expression of connexin26 in islets of Langerhans is associated with impaired glucose tolerance in patients with pancreatic adenocarcinoma.