A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery.

OBJECTIVE: The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA: Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. METHODS: A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. RESULTS: Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). CONCLUSION: For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

[Appleby procedure - an option for surgical treatment of pancreatic body tumour infiltrating the celiac axis]. / Appleby-mutét − lehetoség truncus coeliacust infiltráló pancreastest tumor sebészi kezelésére.

CASE PRESENTATION: After neoadjuvant oncological therapy the surgical treatment of distal pancreatic tumour - infiltrating the celiac axis and the stomach - was reported. During the operation resection of the trunc, distal pancreatectomy, splenectomy, total gastrectomy, resection of the left adrenal gland and cholecystectomy were carried out. The patient's clinical course was uneventful, only transient alteration of liver functions was detected. Histological work-up revealed R1 resection, so adjuvant oncological therapy was decided. DISCUSSION: Distal pancreatic tumours are frequently inoperable. Infiltration of the celiac axis was similarly considered, however there is a chance for radical operation by the resection of the trunc, when the pancreaticoduodenal arcade will provide the arterial blood supply to the liver. Based on the above case the operative technique and the relevant questions were discussed. In pancreatic tumour and arterial infiltration the preoperative chemotherapy is absolutely recommended, because there is a chance for radical surgery in case of good response.

[Resection of liver and abdominal wall metastasis 11 years after pancreatoduodenectomy. Case report]. / Metasztázis miatt végzett máj- és hasfalreszekció 11 évvel a pancreatoduodenectomia után.

Pancreatic cancer has adverse prognosis. Disease recurrence is typical and it occurs mainly within the first 2 years postoperatively. However late and soliter metastases are rare. This case report shows the history of a male patient, who was radically operated on for pancreatic cancer. 11 years later a solitary liver metastasis has developed and it was completely removed by resection. 1 year postoperatively the patient is doing well. Our case demonstrates that in patients after resection for pancreatic cancer, redo surgery might be justified in case of late and isolated metastasis. Orv Hetil. 2017; 158(28): 1109-1111.

Pancreatojejunostomy with modified purse-string suture technique.

PURPOSE: Despite many efforts, pancreatic fistula remains the most troublesome complication following pancreatic resections, especially in case of anastomosis made with soft pancreatic tissue. The purpose of the authors was to show their modification of purse-string pancreatodigestive anastomosis and the results obtained. METHODS: Between January 2013 and June 2015, the technique was applied in 49 patients; one purse-string suture and two U-shaped mattress sutures were used to create the pancreatojejunal anastomosis. In case of soft pancreatic parenchyma, an external stent was temporarily left in the main pancreatic duct. The most frequent pathology was pancreatic cancer, and a pylorus-preserving Whipple procedure was mostly done. RESULTS: Postoperative early morbidity rate was 35 %. There were two fistulas, one grade A fistula from a fibrotic pancreas (4.2 %) and one grade B in case of a soft pancreas (4 %). However, there was no reoperation and mortality. CONCLUSIONS: According to favorable results, the modification of the purse-string suture technique makes this method even safer.

Genetic analysis of the bicarbonate secreting anion exchanger SLC26A6 in chronic pancreatitis.

BACKGROUND: Pancreatic ductal HCO3(-) secretion is critically dependent on the cystic fibrosis transmembrane conductance regulator chloride channel (CFTR) and the solute-linked carrier 26 member 6 anion transporter (SLC26A6). Deterioration of HCO3(-) secretion is observed in chronic pancreatitis (CP), and CFTR mutations increase CP risk. Therefore, SLC26A6 is a reasonable candidate for a CP susceptibility gene, which has not been investigated in CP patients so far. METHODS: As a first screening cohort, 106 subjects with CP and 99 control subjects with no pancreatic disease were recruited from the Hungarian National Pancreas Registry. In 60 non-alcoholic CP cases the entire SLC26A6 coding region was sequenced. In the Hungarian cohort variants c.616G > A (p.V206M) and c.1191C > A (p.P397=) were further genotyped by restriction fragment length polymorphism analysis. In a German replication cohort all exons were sequenced in 40 non-alcoholic CP cases and variant c.616G > A (p.V206M) was further analyzed by sequencing in 321 CP cases and 171 controls. RESULTS: Sequencing of the entire coding region revealed four common variants: intronic variants c.23 + 78_110del, c.183-4C > A, c.1134 + 32C > A, and missense variant c.616G > A (p.V206M) which were found in linkage disequilibrium indicating a conserved haplotype. The distribution of the haplotype did not show a significant difference between patients and controls in the two cohorts. A synonymous variant c.1191C > A (p.P397=) and two intronic variants c.1248 + 9_20del and c.-10C > T were detected in single cases. CONCLUSION: Our data show that SLC26A6 variants do not alter the risk for the development of CP.

[Autoimmune pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Autoimmun pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Autoimmune pancreatitis is a rare disease which can even mimic pancreatic tumor, however, unlike the latter, it requires not surgical but conservative management. Correct diagnosis and differential diagnosis of autoimmune pancreatitis and treatment of these patients requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 29 relevant clinical questions in 4 topics were defined (Basics; Diagnosis; Differential diagnostics; Therapy). Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinial questions were accepted with almost total (more than 95%) agreement. The present guideline is the first evidence based autoimmune pancreatitis guideline in Hungary. The guideline may provide very important and helpful data for tuition of autoimmune pancreatitis, for everyday practice and for establishing proper finance. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.

[Pediatric pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Gyermekkori pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Pediatric pancreatitis is a rare disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has been increased. The management of pediatric pancreatitis requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. In 8 clinical topics (diagnosis; etiology; prognosis; imaging; therapy; biliary tract management; complications; chronic pancreatitis) 50 relevant questions were defined. Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinical statements were accepted with total (more than 95%) agreement. The present Hungarian Pancreatic Study Group guideline is the first evidence based pediatric pancreatitis guideline in Hungary. The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care in pediatric pancreatitis and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

[Pancreatic cancer. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Pancreasrák. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

[Acute pancreatitis. Evidence-based practice guidelines, prepared by the Hungarian Pancreatic Study Group]. / Akut pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Acute pancreatitis is one of the most common diseases of the gastrointestinal tract associated with significant morbidity and mortality that requires up-to-date and evidence based treatment guidelines. The Hungarian Pancreatic Study Group proposed to prepare evidence based guideline for the medical and surgical management of acute pancreatitis based on the available international guidelines and evidence. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and, if it was necessary, complemented and/or modified the international guidelines. All together 42 relevant clinical questions were defined in 11 topics (Diagnosis and etiology, Prognosis, Imaging, Fluid therapy, Intensive care management, Prevention of infectious complications, Nutrition, Biliary interventions, Post-endoscopic retrograde cholangio-pancreatography pancreatitis, Indication, timing and strategy for intervention in necrotizing pancreatitis, Timing of cholecystectomy [or endoscopic sphincterotomy]). Evidence was classified according to the UpToDate® grading system. The draft of the guideline was presented and discussed at the consensus meeting on September 12, 2014. 25 clinical questions with almost total (more than 95%) and 17 clinical questions with strong (more than 70%) agreement were accepted. The present guideline is the first evidence based acute pancreatitis guideline in Hungary. The guideline may provide important help for tuition, everyday practice and for establishment of proper finance of acute pancreatitis. Therefore, the authors believe that these guidelines will widely become as basic reference in Hungary.

[Chronic pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Krónikus pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage of the pancreas. In most cases pain, maldigestion and weight loss are the leading symptoms, which significantly worsen the quality of life. Correct diagnosis and differential diagnosis of chronic pancreatitis and treatment of these patients requires up-to-date and evidence based treatment guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidence. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 123 relevant clinical questions in 11 topics were defined. Evidence was classified according to the UpToDate® grading system. The draft of the guidelines were presented and discussed at the consensus meeting in September 12, 2014. All clinical questions were accepted with total or strong agreement. The present guideline is the first evidence based guideline for chronic pancreatitis in Hungary. This guideline provides very important and helpful data for tuition, everyday practice and proper financing of chronic pancreatitis. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.

Smooth muscle-depressant activity of AP-18, a putative TRPA1 antagonist in the guinea pig intestine.

AP-18, a putative antagonist at TRPA1 receptor/ion channel, caused smooth muscle relaxation at 10-100 µmol/l. It inhibited cholinergic twitch responses evoked by electrical field stimulation of cholinergic nerves as well as contractions in response to acetylcholine and histamine in the guinea pig small intestine. AP-18 (30 µmol/l) blocked spontaneous contractions of longitudinal strips of human jejunum. It is concluded that AP-18 may have limited value in studying TRPA1-mediated responses in smooth muscles and should probably be used with care in other preparations because of possible nonspecific effects.

[Our innovations for the reduction of postoperative pancreatic fistula output]. / A posztoperatív pancreasfistula csökkentésére bevezetett innovációink.

Bevezetés: A posztoperatív pancreasfistula mind proximalis, mind distalis pancreatectomia után a legjelentosebb sebészi szövodménynek számít. A szakirodalomban nincs egyértelmuen ajánlott, megbízható módszer ezen probléma kiküszöbölésére, emiatt történnek újítások szerte a világon. Jelen közleményünkben a technikai innovációinkról számolunk be. Anyag és módszerek: 2013. január 1-jétol 2023. november 30-ig terjedo idoszakban 205 Whipple-mutétet végeztünk nyitottan, mely során a pancreatojejunalis anastomosist az általunk módosított dohányzacskó-öltéses módszerrel készítettük el. 2019. január 1. és 2023. november 30. között pedig 30 betegnél történt nyitott distalis pancreatectomia, amikor a pancreascsonkot az általunk kifejlesztett technikával, szabad rectus fascia-peritoneum grafttal fedtük, majd azt cirkuláris öltéssel rögzítettük. Közleményünkben ezen két módszerrel elért eredményeket ismertetjük. Eredmények: a demográfiai adatok megfeleltek a betegségnél szokásosnak. A posztoperatív ápolási ido és a transzfúzió igény terén észlelt különbségek tükrözték a kétféle beavatkozás eltéro invazivitását. A releváns pancreasfistula kialakulási rátája kedvezo képet mutatott, Whipple-mutét után 7,3% volt, míg distalis pancreatectomát követoen nem fejlodött ki. A reoperációs és a halálozási arányok megfeleltek az elvártaknak és korreláltak a mutétek kiterjedtségével. Következtetés: pancreas resectiók utáni komplikációk csökkentésére tett törekvéseink során a módosított dohányzacskó-öltéses pancreatojejunostomia és a pancreascsonk fedésére kidolgozott módszerünk egyaránt kedvezo eredményekkel járt.

Rupture of pseudoaneurysm into hepaticojejunal anastomosis: report of three cases.

Bleeding complications are less common after major pancreatic resections. They are more often associated with pancreatic fistula. The authors present three cases of a unique situation, when pseudoaneurysm of the common hepatic artery ruptured into the hepaticojejunal anastomosis, causing massive upper gastrointestinal haemorrhage. The basic operations were pancreatic resections for malignancy. In two out of the three cases intra-abdominal infection developed postoperatively. Computer tomographic angiography was a useful tool to reveal the source of bleeding. A re-do surgery was carried out whereby bleeding control was achieved with haemostatic sutures and the biliodigestive anastomoses were also repaired. Re-bleeding did not occur postoperatively and the liver function remained normal. The authors emphasize that in case of severe gastrointestinal bleeding after pancreatic resection, this rare entity ought to be taken into account in the differential diagnosis.

Ganglioneuroma in the papilla of Vater with neurofibromatosis type 1: report of a case.

Ganglioneuromas (GNs) are rare benign tumors and their association with neurofibromatosis type 1 (NF-1) is especially uncommon. We report in this article the case of a young woman, subjected to diagnostic work-up because of abdominal pain. Endoscopy and histology revealed not only a GN in the papilla of Vater, but also NF-1. Because of the size and macroscopic features of the lesion, we performed pancreatoduodenectomy, from which she recovered uneventfully. Histological examination of the resected tumor confirmed a diagnosis of GN.

[Pancreatojejunostomy--with purse-string suture]. / Pancreatojejunostomia - dohányzacskóöltéssel.

INTRODUCTION: Pancreatic fistula is one of the most relevant complications following pancreatoduodenectomies. Significant effort has been made to decrease it. The aim of the authors was to show a pancreatojejunal anastomosis combined with purse-string suture, and report the first experiences, as well. MATERIAL AND METHODS: The implantation pancreatojejunostomy - which has been applied by the authors since 2003 - was modified, that the remnant of the pancreas was fixed in the jejunum with one purse-string and two mattress sutures. In case of a soft pancreas the Wirsungian duct was stented, then the vein canule was pulled out to the outside throught the afferent jejunal limb. The method was applied in seven patients during pylorus-preserving pancreatoduodenectomy performed for neoplasm. RESULTS: In the postoperative period there were two complications in two patients noted (a bleeding ulcer developed in the region of the duodenojejunostomy and a transient confusion). However there was no pancreatic fistula, reoperation or early mortality detected. CONCLUSIONS: While major conclusions can not be drawn due to the relatively small number of cases, this method seems promising and it is worth to carry out further trials.

[Pancreatic cancer with liver metastases: is it possible to improve survival by resection of oligopersistent primary tumor following neoadjuvant chemotherapy?] / Májáttétes pancreasrák: meghosszabbítható-e a túlélés az oligoperzisztens primer daganat neoadjuváns kemoterápiát követo reszekciójával?

The prognosis of pancreatic cancer is one of the worst of all cancers. Though the routine use of modern targeted and immunotherapy is still pending, the recently applied new chemotherapy combinations resulted in obvious improvement in the clinical management of pancreatic cancer. Adjuvant treatment followed by radical operation can increase the survival of the patients, moreover, neoadjuvant therapy for locally advanced tumors is associated with higher resectability rate. However, in metastatic disease only palliative chemotherapy could be indicated due to the dismal prognosis. The introduction of new chemotherapy combinations produced a major evolution by extending the median survival time of these patients. According to recent publications, even complete remission of the metastases can be achieved by the palliative chemotherapy, justifying a radical operation. This approach can be more advantageous, compared to patients treated with chemotherapy only. Reporting our two primary metastatic cases, we also endorse this new approach. The clinical significance of complex management is justified in the case of oligopersistence which is traditionally treated only with palliative systemic therapy. Orv Hetil. 2023; 164(43): 1712-1718.

Krónikus pancreatitis miatt végzett pancreasfej-resectiós mutéteink elemzése.

Introduction: In case of chronic pancreatitis with inflammatory enlargement of the pancreatic head, several operations exist for the treatment, such as the Beger-, Frey-, Whipple-procedures and the Berne modification. A comparison of the results of these procedures is presented in this study. In addition to this, innovations in pancreatojejunal and biliodigestive anastomosis are also described. Material and Methods: 231 pancreatic head resections were carried out between 1991 and 2021. The data were retrospectively evaluated. Late results were also examined using questionnaires. Results: The Berne modification and the Frey-procedure were more advantageous, than the Whipple- and the Beger-operation in terms of operating time, need for transfusion (P < 0,001), while regarding, the postoperative intensive care unit and total hospital stay both procedures were more favourable, than the Whipple one (P < 0,001). The early morbidity rate was the highest after the Whipple-procedure (P = 0,004). These differences were statistically significant. The reoperation and mortality rates were comparable between the groups. The quality of life of the patients was acceptable, nevertheless in the majority of the cases the alcohol and nicotine abuse was not stopped. Conclusion: The Frey-operation and the Berne modification were the most advantageous, regarding the early postoperative outcomes. However the latter one is preferable, due to its simplicity. During these procedures a single layer continuous suture technique was used for the pancreatojejunal anastomosis, and an extrapancreatic biliodigestive anastomosis is recommended for the solution of cholestasis. due to the superior results.

[Experiences with central pancreatectomy]. / Centrális pancreatectomiával szerzett tapasztalataink.

INTRODUCTION: The authors report their experience with central pancreatectomy and also summarize relevant literature data. MATERIAL AND METHODS: Central pancreatectomies were performed in 7 patients for benign or low-grade malignant pancreatic neoplasms, or pancreatic rupture in one patient. Most frequently applied anastomosis was between the distal part of the pancreas and a Roux-en-Y limb, while the proximal cut surface was closed with sutures, and the suture line was covered with a limb. RESULTS: There were three complications (37%), but reoperation didn't need to be performed and none of the patients died. We did not detect any deterioration in the exocrine or endocrine function during the follow-up period. CONCLUSIONS: Central pancreatectomy is a safe procedure with excellent functional results, if both the indication and the applied technique are chosen appropriately.

[Our efforts to decrease surgical complications following pancreatic resections]. / Törekvéseink a pancreasresectiókat követo sebészi szövodmények csökkentésére.

INTRODUCTION: The most frequent surgical complications following pancreatic resections are pancreatic fistula and delayed gastric emptying. The aim of the authors was to analyse these complications in their own practice. MATERIAL AND METHODS: Clinical data of 287 patients were reviewed, who were radically operated on for malignant pancreatic or periampullary tumours during 14 years period. The most common neoplasm was pancreatic adenocarcinoma, located in the head of the pancreas. Pylorus-preserving pancreatoduodenectomy was most frequently performed. In the early period pancreatogastrostomy and double-layer pancreatojejunostomy were preferred during the reconstruction, as well as retrocolic duodeno-, and gastrojejunostomy, respectively. Later the authors turned to the single-layer implantation pancreatojejunostomy and to the antecolic reconstruction, the latter was completed with Braun anastomosis. RESULTS: In the postoperative course complications occurred in 39%, reoperation was done in 5.6%, and the early mortality rate was 3.8%. The rate of pancreatic fistula decreased to 5.9% following single-layer pancreatojejunostomy, and the difference was significant compared to the 17.6% rate after pancreatogastrostomy. Due to the antecolic reconstruction the frequency of delayed gastric emptying has reduced from 10.2% to 2.1%, which is a statistically significant difference. CONCLUSIONS: As a result of changes in the surgical techniques during the 14 years period, the frequency of pancreatic fistula and delayed gastic emptying has dramatically decreased, which underlines the need of continuous progress in surgical methods.