Strahlenexposition Angehöriger von Patienten nach stationärer Radioiodtherapie durch Inhalation von 131I in der Wohnung

Ziel: Mit Hilfe einer Modellrechnung sollen Exhalationskoeffizienten ermittelt werden, mit deren Hilfe die Exhalation von 1311 von Patienten, die sich einer Radioiodtherapie unterziehen mußten, ermittelt werden kann. Die Richtigkeit dieser Exhalationskoeffizienten soll durch Messungen an Angehörigen der Patienten, die in der Wohnung ausgeatmetes lod der Patienten eingeatmet haben, mit dem Ganzkörperzähler überprüft werden. Auf der Grundlage dieser Exhalationskoeffizienten soll die Exposition der Angehörigen der Patienten berechnet werden. Methoden: Die 1311-Aktivität 17 Angehöriger von Patienten, die sich einer Radioiodtherapie unterziehen mußten, wurde wenige Tage nach der Entlassung des Patienten im Ganzkörperzähler gemessen und mit den Ergebnissen von Modellrechnungen verglichen. Ergebnisse: Zwischen den gemessenen Werten der Körperaktivität (AGK) der Angehörigen von Radioiod-Therapie-Patienten und den berechneten Werten läßt sich eine Korrelation AModell = AGk - 47,3 (r2 = 0,959) ableiten, unter der Voraussetzung, daß 2,1 μg lod von den 60 μg lod, die täglich mit der Nahrung aufgenommen werden, ausgeatmet werden. Die Exposition aller Angehörigen blieb stets unter 100 μSveff. Mit den gleichen Modellparametern ergeben sich unter Annahme einer ambulant durchgeführten Radioiodtherapie effektive Expositionen bei den Angehörigen von bis zu 6,5 mSv. Schlußfolgerung: Die tägliche Exhalation von l31l kann mit Hilfe einer Modellrechnung abgeschätzt werden. Nach einem Aufenthalt von Patienten von 3 Tagen in einer nuklearmedizinischen Therapiestation überschreitet die effektive Äquivalentdosis Angehöriger in der Wohnung des Patienten den Wert 100 μSv durch die Inhalation von 1311 nicht. Das sind 10% des Grenzwertes 1 mSv, den die ICRP 60 empfiehlt. Die ambulante Radioiodtherapie, auch Radioiodtherapietourismus aus Deutschland in benachbarte Staaten, ist aus Strahlenschutzgründen abzulehnen.

Influence of iodine application during radioiodine therapy in case of impending therapy failure

Aim: We investigated whether additional application of “cold” iodine after therapy with radioiodine could result in a prolongation of the effective half life of iodine-131 and would thus lead to an increase of the effective thyroid radiation dose. Methods: Time-activitycurves after therapy with radioiodine were analysed in 25 patients (16 women, 9 men). Nine patients suffered from autonomously functioning thyroid nodules, 5 from autonomous multinodular goiter and 11 from Graves’ disease. These patients had an effective half life shorter than 4 days resulting in an undertreatment of > 20% with respect to the desired effective thyroid radiation dose. 2-4 days after therapy with radioiodine all patients received “cold” iodine for three days in a dose of 3 × 200 μg per day. Results: In 14 of the 25 patients an increase of the effective half life was observed. Patients with an autonomously functioning thyroid nodule showed a mean increase of the effective thyroid radiation dose of 40 ± 44 Gy, patients with toxic multinodular goiter of 29 ± 30 Gy and patients with Graves’ disease of 37 ± 37 Gy. Conclusion: Additional application of “cold” iodine after therapy with radioiodine can prolong the effective half life in selected patients. We suspect a correlation with the thyroid iodine pool. This will be the basis for further investigations hopefully resulting in a better patient preselection to determine who might respond to this therapy.

Laparoscopic or open distal pancreatectomy for benign and malignant lesions of the pancreas?

Minimally-invasive techniques were adopted relatively late for pancreatic procedures due to their complexity. Today, minimally-invasive distal pancreatectomy is the procedure of choice for the treatment of benign or premalignant pancreatic lesions due to the advantages inherent to laparoscopy. Data on the efficacy of minimally-invasive distal pancreatectomy in oncologic surgery is still limited and larger prospective series are needed prior to its widespread use for the treatment of pancreatic cancer. This review addresses various aspects of distal pancreatectomy, with emphasis on recent developments and open controversies.

Administration of additional inactive iodide during radioiodine therapy for Graves' disease

Aim: Graves' hyperthyroidism and antithyroid drugs empty the intrathyroid stores of hormones and iodine. The consequence is rapid 131I turnover and impending failure of radioiodine therapy. Can administration of additional inactive iodide improve 131I kinetics? Patients, methods: Fifteen consecutive patients, in whom the 48 h post-therapeutically calculated thyroid dose was between 150 and 249 Gy due to an unexpectedly short half-life, received 3 × 200 μg inactive potassium-iodide (127I) daily for 3 days (Group A), while 17 consecutive patients with a thyroid dose of ≥ 250 Gy (Group B) served as the non-iodide group. 48 hours after 131I administration (M1) and 4 or 5 days later (M2) the following parameters were compared: effective 131I half-life, thyroid dose, total T3, total T4, 131I-activity in the T3- and T4-RIAs. Results: In Group A, the effective 131I half-life M1 before iodine (3.81 ± 0.93 days) was significantly (p <0.01) shorter than the effective 131I half-life M2 (4.65 ± 0.79 days). Effective 131I half-life M1 correlated with the benefit from inactive 127I (r = –0.79): Administration of 127I was beneficial in patients with an effective 131I half-life M1 of <3 or 4 days. Patients from Group A with high initial specific 131I activity of T3 and T4 showed lower specific 131I activity after addition of inactive iodine compared with patients from the same group with a lower initial specific 131I activity of T3 and T4 and compared with the patient group B who was given no additional inactive iodide. This correlation was mathematically described and reflected in the flatter gradient in Group A (y = 0.5195x + 0.8727 for 131I T3 and y = 1.0827x – 0.4444 for 131I T4) and steeper gradient for Group B (y = 0.6998x + 0.5417 for 131I T3 and y = 1.3191x – 0.2901 for 131I T4). Radioiodine therapy was successful in all 15 patients from Group A. Conclusion: The administration of 600 μg inactive iodide for three days during radioiodine therapy in patients with Graves' hyperthyroidism and an unexpectedly short half-life of <3 or 4 days was a safe and effective alternative to the administration of a second radioiodine capsule

Clinical Characterization of the Pheochromocytoma and Paraganglioma Susceptibility Genes SDHA, TMEM127, MAX, and SDHAF2 for Gene-Informed Prevention

Importance

Effective cancer prevention is based on accurate molecular diagnosis and results of genetic family screening, genotype-informed risk assessment, and tailored strategies for early diagnosis. The expanding etiology for hereditary pheochromocytomas and paragangliomas has recently included SDHA, TMEM127, MAX, and SDHAF2 as susceptibility genes. Clinical management guidelines for patients with germline mutations in these 4 newly included genes are lacking.

Objective

To study the clinical spectra and age-related penetrance of individuals with mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes.

Design, Setting, and Patients

This study analyzed the prospective, longitudinally followed up European-American-Asian Pheochromocytoma-Paraganglioma Registry for prevalence of SDHA, TMEM127, MAX, and SDHAF2 germline mutation carriers from 1993 to 2016. Genetic predictive testing and clinical investigation by imaging from neck to pelvis was offered to mutation-positive registrants and their relatives to clinically characterize the pheochromocytoma/paraganglioma diseases associated with mutations of the 4 new genes.

Main Outcomes and Measures

Prevalence and spectra of germline mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes were assessed. The clinical features of SDHA, TMEM127, MAX, and SDHAF2 disease were characterized.

Results

Of 972 unrelated registrants without mutations in the classic pheochromocytoma- and paraganglioma-associated genes (632 female [65.0%] and 340 male [35.0%]; age range, 8-80; mean [SD] age, 41.0 [13.3] years), 58 (6.0%) carried germline mutations of interest, including 29 SDHA, 20 TMEM127, 8 MAX, and 1 SDHAF2. Fifty-three of 58 patients (91%) had familial, multiple, extra-adrenal, and/or malignant tumors and/or were younger than 40 years. Newly uncovered are 7 of 63 (11%) malignant pheochromocytomas and paragangliomas in SDHA and TMEM127 disease. SDHA disease occurred as early as 8 years of age. Extra-adrenal tumors occurred in 28 mutation carriers (48%) and in 23 of 29 SDHA mutation carriers (79%), particularly with head and neck paraganglioma. MAX disease occurred almost exclusively in the adrenal glands with frequently bilateral tumors. Penetrance in the largest subset, SDHA carriers, was 39% at 40 years of age and is statistically different in index patients (45%) vs mutation-carrying relatives (13%; P < .001).

Conclusions and Relevance

The SDHA, TMEM127, MAX, and SDHAF2 genes may contribute to hereditary pheochromocytoma and paraganglioma. Genetic testing is recommended in patients at clinically high risk if the classic genes are mutation negative. Gene-specific prevention and/or early detection requires regular, systematic whole-body investigation.

High Density of Tumor-infiltrating B-Lymphocytes and Plasma Cells Signifies Prolonged Overall Survival in Adenocarcinoma of the Esophagogastric Junction

BACKGROUND

Tumor-infiltrating lymphocytes (TILs) have been shown to be of prognostic significance in a variety of tumors. Not only T-cell, but also B-cell infiltration is commonly associated with improved survival.

MATERIALS AND METHODS

We assessed the density of tumor-infiltrating B-cells, as well as that of plasma cells, in 210 adenocarcinomas of the esophagogastric junction through immunohistochemical analysis using antibodies against CD20 and CD138.

RESULTS

No correlation between density of B-cells or plasma cells and various clinicopathologic features could be established. High density of tumor-infiltrating B-cells, as well as plasma cells, showed significantly better overall survival (OS) compared to patients with no infiltrates (p=0.047 and p=0.022, respectively). Cox proportional hazard analysis could verify B-cell infiltration as an independent prognostic factor (hazard ratio (HR)=0.683; 95% confidence interval (CI)=0.517-0.901; p=0.007).

CONCLUSION

Plasma cell and B-cell infiltration correlates with prolonged OS and might identify a patient subset with favorable disease course.

Expression of cyclooxygenase-2 has no impact on survival in adenocarcinoma of the esophagogastric junction but is associated with favourable clinicopathologic features

BACKGROUND

COX-2 expression induces carcinogenesis and is thought to be an adverse prognostic factor in gastric carcinomas while the prognostic value of DNA mismatch repair (MMR) is still controversial. Concerning adenocarcinomas of the esophagogastric junction, no comprehensive data regarding either factors are available as of yet.

OBJECTIVE

We assessed expression of COX-2, MLH1 and MSH2 in adenocarcinoma of the esophagogastric junction in relation to patients' survival and various clinicopathologic features.

DESIGN

Immunohistochemical studies (using antibodies against COX-2, MLH1 and MSH2) were performed in a study population of 228 tumours. Follow-up data was available for all patients with a mean follow-up time of 42.8 months.

RESULTS

78 (34.2%) tumours were COX-2 negative, 148 (64.9%) showed COX-2 positivity. Assessment of COX-2 expression and clinicopathologic features revealed an inverse correlation with depth of tumour invasion and number of metastatic lymph nodes (p=0,021 and p=0,004, respectively). No correlation with other features could be demonstrated. 62 cases (27.2%) showed loss of DNA repair enzymes MLH1 and/or MSH2. MMR differed significantly between COX-2 positive and negative cases (p=0,028). Kaplan-Meier survival analyses revealed no impact on patients' survival for COX-2 expression or MMR status (p=0.837 and p=0.972, respectively).

CONCLUSIONS

Expression of COX-2 in adenocarcinomas of the esophagogastric junction seems to have no prognostic effect or impact on patients' survival but is associated with favourable clinicopathologic factors. MMR deficiency was more frequent in COX-2 negative tumours, but MMR status had no impact on survival and patients' outcome whatsoever.

The role of endoscopy in pediatric gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Gastrointestinal bleeding in children and adolescents accounts for up to 20 % of referrals to gastroenterologists. Detailed management guidelines exist for gastrointestinal bleeding in adults, but they do not encompass children and adolescents. The aim of this study was to assess gastrointestinal bleeding in pediatric patients and to determine an investigative management algorithm accounting for the specifics of children and adolescents.

PATIENTS AND METHODS

Pediatric patients with gastrointestinal bleeding admitted to our endoscopy unit from 2001 to 2009 (n = 154) were identified. Retrospective statistical and neural network analysis was used to assess outcome and to determine an investigative management algorithm.

RESULTS

The source of bleeding could be identified in 81 % (n = 124/154). Gastrointestinal bleeding was predominantly lower gastrointestinal bleeding (66 %, n = 101); upper gastrointestinal bleeding was much less common (14 %, n = 21). Hematochezia was observed in 94 % of the patients with lower gastrointestinal bleeding (n = 95 of 101). Hematemesis (67 %, n = 14 of 21) and melena (48 %, n = 10 of 21) were associated with upper gastrointestinal bleeding. The sensitivity and specificity of a neural network to predict lower gastrointestinal bleeding were 98 % and 63.6 %, respectively and to predict upper gastrointestinal bleeding were 75 % and 96 % respectively. The sensitivity and specifity of hematochezia alone to predict lower gastrointestinal bleeding were 94.2 % and 85.7 %, respectively. The sensitivity and specificity for hematemesis and melena to predict upper gastrointestinal bleeding were 82.6 % and 94 %, respectively. We then developed an investigative management algorithm based on the presence of hematochezia and hematemesis or melena.

CONCLUSIONS

Hematochezia should prompt colonoscopy and hematemesis or melena should prompt esophagogastroduodenoscopy. If no source of bleeding is found, additional procedures are often non-diagnostic.

Diverse prognostic value of the GTn promoter polymorphism in squamous cell and adeno carcinoma of the oesophagus

The basal transcription of heme oxygenase-1 (HO-1) regulation is dependent upon a GT repeat germ line polymorphism (GTn) in the promoter of the HO-1 gene. We determined the prognostic value of HO-1 promoter polymorphism on the natural postoperative course of complete resected oesophageal cancer. Genomic DNA from 297 patients was amplified by polymerase chain reaction and sequenced. The results were correlated with clinicopathological parameters, disseminated tumour cells in bone marrow (DTC) and clinical outcome. Depending on short allele with <25 and long allele with ≥25, GTn repeats three genotypes (SS, SL and LL) were defined. A diverse role of GTn was evident in squamous cell carcinoma (SCC) and adenocarcinoma (AC). In SCC, the SS genotype presented less advanced tumours with lower rate DTC in bone marrow and relapse compared with L-allele carriers. In contrast, AC patients with the SS genotype displayed a complete opposing tumour characteristic. The disease-free (DFS) and overall survival (OS) in SCC patients was markedly reduced in LL genotypes (p < 0.001). In AC contrarily the SS genotype patients displayed the worst DFS and OS (p < 0.001). GTn is a strong prognostic factor with diverse prognostic value for recurrence and survival in AC and SCC.

ZEB1-associated drug resistance in cancer cells is reversed by the class I HDAC inhibitor mocetinostat

Therapy resistance is a major clinical problem in cancer medicine and crucial for disease relapse and progression. Therefore, the clinical need to overcome it, particularly for aggressive tumors such as pancreatic cancer, is very high. Aberrant activation of an epithelial-mesenchymal transition (EMT) and an associated cancer stem cell phenotype are considered a major cause of therapy resistance. Particularly, the EMT-activator ZEB1 was shown to confer stemness and resistance. We applied a systematic, stepwise strategy to interfere with ZEB1 function, aiming to overcome drug resistance. This led to the identification of both its target gene miR-203 as a major drug sensitizer and subsequently the class I HDAC inhibitor mocetinostat as epigenetic drug to interfere with ZEB1 function, restore miR-203 expression, repress stemness properties, and induce sensitivity against chemotherapy. Thereby, mocetinostat turned out to be more effective than other HDAC inhibitors, such as SAHA, indicating the relevance of the screening strategy. Our data encourage the application of mechanism-based combinations of selected epigenetic drugs with standard chemotherapy for the rational treatment of aggressive solid tumors, such as pancreatic cancer.

Evaluation of the germline single nucleotide polymorphism rs583522 in the TNFAIP3 gene as a prognostic marker in esophageal cancer

Most esophageal cancer patients die because of disease relapse, hence an accurate prognosis of disease relapse and survival is essential. Genetic variations in cancer patients may serve as important indicators. Three genotypes (GG, AG, and AA) are displayed by the single nucleotide polymorphism (SNP) rs583522, which maps to the TNFAIP3 gene on chromosome 6. Evaluation of the potential prognostic value of the TNFAIP3-SNP in esophageal cancer (EC) was the aim of this study. A total of 158 patients underwent complete surgical resection of the esophagus for EC. None of them received any neoadjuvant or adjuvant treatment. Peripheral blood was sampled, and genomic DNA was extracted from leukocytes before each operation. Clinicopathologic parameters, tumor cell dissemination in bone marrow, and clinical outcome were correlated with the TNFAIP3-SNP. A-allele carriers showed advanced tumor stages compared with those of homozygous G-allele carriers (P<0.001). Patients with an A-allele genotype (AA or AG) were significantly more likely to experience a relapse (P=0.003). Survival analysis (log-rank test) revealed a significant difference in overall survival between the three groups (P=0.039); however, none of the genotypes was identified as a disease stage-independent prognostic marker. In conclusion, TNFAIP3-SNP stratifies patients into different risk groups; however, it could not be identified as an independent prognostic marker.

Predicting Survival After Irradiation of Metastases from Pancreatic Cancer

BACKGROUND/AIM

Patients with metastases from pancreas cancer benefit from individualized care, including radiotherapy for symptom control. To administer the optimal radiation therapy, it is important to understand a patient's prognosis.

PATIENTS AND METHODS

Seven variables were analyzed regarding their relationship with survival: age, gender, Karnofsky performance score (KPS), number of metastatic sites, interval from diagnosis of pancreatic cancer to irradiation of metastases, type of irradiated metastasis, and radiation dose.

RESULTS

On univariate analysis, survival was positively associated with age ≤ 67 years (p=0.045), KPS >70 (p<0.001), and involvement of only one metastatic site (p=0.013). A longer interval between diagnosis and irradiation of metastases showed a trend for better survival (p=0.077). On multivariate analysis, age [risk ratio (RR)=4.29; p=0.004], KPS (RR=1.95; p=0.020), number of metastatic sites (RR=2.20; p=0.009) and interval to irradiation (RR=4.41; p=0.005) achieved significance.

CONCLUSION

The present study identified four independent predictors of survival in patients with pancreatic cancer irradiated for metastasis and thus contributes to treatment optimization.

A self-enforcing CD44s/ZEB1 feedback loop maintains EMT and stemness properties in cancer cells

Invasion and metastasis of carcinomas are often activated by induction of aberrant epithelial-mesenchymal transition (EMT). This is mainly driven by the transcription factor ZEB1, promoting tumor-initiating capacity correlated with increased expression of the putative stem cell marker CD44. However, the direct link between ZEB1, CD44 and tumourigenesis is still enigmatic. Remarkably, EMT-induced repression of ESRP1 controls alternative splicing of CD44, causing a shift in the expression from the variant CD44v to the standard CD44s isoform. We analyzed whether CD44 and ZEB1 regulate each other and show that ZEB1 controls CD44s splicing by repression of ESRP1 in breast and pancreatic cancer. Intriguingly, CD44s itself activates the expression of ZEB1, resulting in a self-sustaining ZEB1 and CD44s expression. Activation of this novel CD44s-ZEB1 regulatory loop has functional impact on tumor cells, as evident by increased tumor-sphere initiation capacity, drug-resistance and tumor recurrence. In summary, we identified a self-enforcing feedback loop that employs CD44s to activate ZEB1 expression. This renders tumor cell stemness independent of external stimuli, as ZEB1 downregulates ESRP1, further promoting CD44s isoform synthesis.

A prospective clinical study evaluating the development of bowel wall edema during laparoscopic and open visceral surgery

BACKGROUND

To examine bowel wall edema development in laparoscopic and open major visceral surgery.

METHODS

In a prospective study, 47 consecutively operated patients with gastric and pancreatic resections were included. Twenty-seven patients were operated in a conventional open procedure (open group) and 20 in a laparoscopic fashion (lap group). In all procedures, a small jejunal segment was resected during standard preparation, of which we measured the dry-wet ratio. Furthermore, HE staining was performed for measuring of bowel wall thickness and edema assessment.

RESULTS

Mean value (±std) of dry-wet ratio was significantly lower in the open than in the lap group (0.169 ± 0.017 versus 0.179 ± 0.015; p = 0.03) with the same amount of fluid administration in both groups and a longer infusion interval during laparoscopic surgery. Subgroup analyses (only pancreatic resections) still showed similar results. Histologic examination depicted a significantly larger bowel wall thickness in the open group.

CONCLUSIONS

Laparoscopic surgery does not seem to lead to the bowel wall edema observed to occur in open surgery regardless of the degree of intravenous fluid administration, thus supporting its use even in major visceral surgery.

Long-term prognosis of patients with pediatric pheochromocytoma

A third of patients with paraganglial tumors, pheochromocytoma, and paraganglioma, carry germline mutations in one of the susceptibility genes, RET, VHL, NF1, SDHAF2, SDHA, SDHB, SDHC, SDHD, TMEM127, and MAX. Despite increasing importance, data for long-term prognosis are scarce in pediatric presentations. The European-American-Pheochromocytoma-Paraganglioma-Registry, with a total of 2001 patients with confirmed paraganglial tumors, was the platform for this study. Molecular genetic and phenotypic classification and assessment of gene-specific long-term outcome with second and/or malignant paraganglial tumors and life expectancy were performed in patients diagnosed at <18 years. Of 177 eligible registrants, 80% had mutations, 49% VHL, 15% SDHB, 10% SDHD, 4% NF1, and one patient each in RET, SDHA, and SDHC. A second primary paraganglial tumor developed in 38% with increasing frequency over time, reaching 50% at 30 years after initial diagnosis. Their prevalence was associated with hereditary disease (P=0.001), particularly in VHL and SDHD mutation carriers (VHL vs others, P=0.001 and SDHD vs others, P=0.042). A total of 16 (9%) patients with hereditary disease had malignant tumors, ten at initial diagnosis and another six during follow-up. The highest prevalence was associated with SDHB (SDHB vs others, P<0.001). Eight patients died (5%), all of whom had germline mutations. Mean life expectancy was 62 years with hereditary disease. Hereditary disease and the underlying germline mutation define the long-term prognosis of pediatric patients in terms of prevalence and time of second primaries, malignant transformation, and survival. Based on these data, gene-adjusted, specific surveillance guidelines can help effective preventive medicine.

Grenzen des laparoskopischen Operierens bei abdomineller Sepsis

<b><i>Hintergrund: </i></b>Zahlreiche präklinische Daten weisen auf Vorteile des laparoskopischen Operierens auch bei abdomineller Sepsisquelle und septischem Patienten hin. <b><i>Methode und Ergebnisse: </i></b>Anhand derzeit verfügbarer Literatur betrachten wir die Möglichkeiten und Limitierungen laparoskopischen Operierens beim septischen Patienten mit abdominellem Fokus. Neben generellen Überlegungen werden im Speziellen das Vorgehen bei Appendizitis, Cholezystitis, perforiertem Ulkus, Sigmadivertikulitis und akuter Pankreatitis erörtert. <b><i>Schlussfolgerungen: </i></b>Erfahrene laparoskopische Chirurgen können die Sanierung der abdominellen Sepsisquelle bei Appendizitis, Cholezystitis, perforiertem Ulkus oder auch Sigmadivertikulitis sicher durchführen. Kombinationen aus interventionellen Techniken und minimal invasiven Operationen bieten insbesondere bei der perforierten Sigmadivertikulitis und bei infizierten Pankreasnekrosen innovative Ansätze, die derzeit in multizentrischen prospektiven Studien untersucht werden.

Short- and long-term results of duodenum preservation versus resection for the management of chronic pancreatitis: a prospective, randomized study

BACKGROUND

Individualization of operations for chronic pancreatitis (CP) offers tailored operative approaches for the management of complications of CP. For the management of the inflammatory head mass and its complications, duodenum-preserving procedures (Frey and Beger operations) compete in efficacy and quality of life with pancreatoduodenectomy procedures (PPPD and Whipple operations). Our aim was to compare the short- and long-term results of duodenum-preserving and duodenum-resecting techniques in a prospective, randomized trial.

METHODS

Eighty-five patients with CP were randomized to undergo either pylorus-preserving (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). Perioperative and long term results were evaluated.

RESULTS

Although the duodenum-preserving operations had a lesser median operating time (360 vs 435 minutes; P = .002), there were no differences in the need for intraoperative blood transfusion (76% vs 79%) or the duration of hospital stay (13 vs 14 days). Postoperative complications in general (33% vs 30%), surgical complications (21% vs 23%), and severe complications such as pancreatic leakage (10% vs 5%) or the need for reoperation (2% vs 2%) did not differ between the DPPHR and the PPPD groups, and there was no mortality (0%). The long-term outcome after a median of >5 years showed no differences between the DPPHR and PPPD regarding quality of life, pain control (67% vs 67%), endocrine status (45% vs 44%), and exocrine insufficiency (76% vs 61%).

CONCLUSION

Both types of pancreatic head resections are equally effective in pain relief and eventual quality of life after long-term follow-up (>5 years) without differences in endocrine or exocrine function.

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

[Laparoscopic resection of the pancreatic head. Feasibility and perioperative results]

BACKGROUND

Whereas pancreatic tail resection is routinely and safely performed in several institutions, laparoscopic resection of the pancreatic head is only performed by a handful of surgeons worldwide, none of them in Germany.

PATIENTS AND METHODS

We review our experience with 9 laparoscopic pancreatic head resections (lap-PPPD) performed between March and September 2010. The operations were performed using a hybrid approach with complete laparoscopic pylorus-preserving pancreatic head resection and successive reconstruction via a small retrieval incision. Perioperative outcome was compared to 605 open pancreatic head resections (1997-2010).

RESULTS

In the group lap-PPPD 3 out of 9 conversions had to be performed due to oncologic reasons. There were no significant differences in perioperative outcome when comparing open-PPPD to lap-PPPD.

CONCLUSION

Laparoscopic pancreatic head resection with hybrid open reconstruction combines the potential advantages of laparoscopic resection with the safety of an open pancreatic anastomosis. Even at the beginning of the learning curve the procedure can be performed with no concessions to safety or duration of the operation.