[Massive pleural effusion complicating chronic pancreatitis. Treatment by endoscopic closure of a pancreatic-mediastinal fistula]. / Ausgedehnter Pleuraerguss bei chronischer Pankreatitis. Behandlung durch endoskopischen Verschluss einer pankreatikomediastinalen Fistel.

HISTORY AND CLINICAL FINDINGS: A 53-year-old man was admitted because of anuria, dyspnea and a septic temperature. The patients' history included chronic alcoholism, chronic pancreatitis, COPD and a right nephrectomy because of nephrolithiasis. Urosepsis was initially suspected. INVESTIGATIONS: The patients' clinical condition and nutritional state were severely reduced. Laboratory findings revealed severe systemic inflammation (leucocyte count: 22.4/nl, CRP: 324 mg/l). Computed tomography showed a large left-sided pleural effusion, encapsulated abdominal fluid below the diaphragm and alongside the pancreatic tail. After aspiration of the pleural effusion the diagnosis of an exsudate with elevated concentration of lipase (56,000 U/l) was confirmed. Endoscopic ultrasound showed a 3-4 cm pseudocystic mass originating in the region of the pancreatic tail. The ERP depicted chronic pancreatitis with strictures and destruction of the pancreatic duct. Two fistulae were identified, one proximal to a ductal stricture in the pancreatic head and a second one in the pancreatic tail which corresponded to the reported pseudocyst. TREATMENT AND CLINICAL COURSE: The patient was admitted to the ICU with symptoms of impending sepsis. The pleural effusion was treated with CT-guided chest drainage. The initial endoscopic attempt at stent closure of the fistula failed because it was possible to pass through the ductal stricture only with a thin hydrophilic wire and small-lumen catheter. However, injection of fibrin glue into the proximal pancreatic duct over a length of 2 cm obliterated the fistula and the pleural effusion was resolved. CONCLUSION: Pancreatic-pleural or pancreatic-mediastinal fistula is a rare complication of pancreatitis associated with unilateral pleural effusion. Combined internal endoscopic drainage and external chest drainage is the treatment of choice. After failure of routine endoscopic therapy, endoscopic closure of fistulas using fibrin glue might offer an alternative treatment strategy.

[Prediction of perioperative mortality in patients with advanced liver disease and abdominal surgery by the use of different scoring systems and tests]. / Prädiktion der perioperativen Mortalität bei Patienten mit fortgeschrittener Lebererkrankung und abdominalchirurgischen Eingriffen anhand unterschiedlicher Score- und Testsysteme.

Patients with advanced liver disease show increased morbidity and mortality after hepatic resection and non-hepatic digestive surgery. Furthermore, postoperative liver failure is associated with a poor outcome, representing an important clinical problem. For evaluation of the perioperative mortality and the hepatic function, several scoring systems, clinical parameters, and static and dynamic tests are available. Recently, the Model for End-Stage Liver Disease (MELD) has been shown to provide a complementary predictive value to the widely used Child Turcotte Pugh score. Patients with Child Turcotte Pugh class C cirrhosis and MELD scores >14 are generally not considered for surgical intervention. Patients with Child Turcotte Pugh class B cirrhosis and MELD scores >8-14 have an increased perioperative risk and the indication for surgery should be assessed carefully. In patients with Child Turcotte Pugh class A cirrhosis and MELD scores of

Value of the serum levels of the tumor marker TUM2-PK in pancreatic cancer.

The monoclonal antibody pyruvate kinase type tumor M2 (TUM2-PK) has been shown to have a high binding capacity to pancreatic cancer. In present study TUM2-PK serum levels were measured in pancreatic cancer and compared with the reference tumor markers CA19-9, CA50, CA72-4 and CEA. Overall 100 patients were included in this study, 64 patients had a histologically confirmed pancreatic carcinoma, 36 patients gastrointestinal cancer (stomach, colon), 666 healthy volunteers served as controls. Measurements were done by enzymimmunoassay. For the healthy blood donors a cut-off value of 22.5 U/ml was evaluated, which corresponds to 95% specificity. In patients with pancreatic cancer the sensitivities of TUM2-PK, CA19-9, CEA, CA72-4 and CA50 were 71%; 68%, 37%, 49% and 63.4% respectively. Linear regression analysis indicated that there was a positive correlation (r = 0.79). According to the results of our study TUM2-PK has comparable sensitivity but higher specificity than the reference tumor marker CA19-9.

[Effects of a nucleotide-nucleoside mixture on ischemic muscle metabolism in patients with stage II peripheral arterial occlusive disease. MR spectroscopic and biochemical analytic results]. / Effekte eines Nukleotid-Nukleosid-Gemisches auf den ischämischen Muskelstoffwechsel bei Patienten mit peripherer arterieller Verschlusskrankheit Stadium II. Mr-spektroskopische und analytisch-biochemische Ergebnisse.

In order to assess the acute metabolic effects of an intra-arterial infusion of nucleotide-nucleoside-mixture (NNM), 31P-mr-spectroscopy at the site of m. gastrocnemius and metabolite determinations from blood of the femoral artery and vein were carried out in 10 patients with PAOD stage II during ergometric calf exercise to the claudication pain limit. The spectroscopic measurements revealed a greater exercise-induced fall of PCr and a higher increase of Pi in calf muscles during supply of NNM compared with control ergometry. Post-exercise recovery of PCr was distinctly delayed during infusion of NNM. The anaerobic production of energy, however, was sufficient to maintain the ATP concentration to the same extent as under control ergometry. On the other hand, intramuscular lactate acidosis developed to a lower degree with NNM infusion than without NNM. A reduced muscular release of lactate, pyruvate, ammonia and alanine followed from the evaluation of the arteriovenous balance of these metabolites in the femoral vessels indicating a favourable global metabolic effect of NNM infusion in the extremity. The apparent contradiction in the spectroscopic and analytic-biochemical findings can be explained by local blood shunts induced by maximum vasodilation. Noninvasive mr-spectroscopy allows to detect directly and continuously the metabolic impact of ischemia in the calf muscles afflicted by arterial occlusion, whereas the metabolite concentrations in femoral blood are altered by afflux from non-ischemic areas. The known clinical benefit of frequently repeated intra-arterial infusions of NNM is thought to be due to an expansion of collateral circulation and to a favourable influence on endothelial functions.