Up-regulation of ICAM-1 during cold ischemia triggers early neutrophil infiltration in human pancreas allograft reperfusion.

BACKGROUND: Graft pancreatitis is induced by ischemia/reperfusion injury in which neutrophil infiltration is believed to be a crucial early event. This observation suggests the presence of adhesion molecules already at the time of reperfusion. Therefore, this study was performed to evaluate the pattern of ICAM-1 and P-Selectin expression on human pancreas allografts following cold ischemia and reperfusion. PATIENTS AND METHODS: We performed an analysis of pancreas biopsy specimens taken from 13 patients undergoing pancreas transplantation compared with pancreas specimens from 10 patients following resection. Cryostat sections were stained with monoclonal antibodies against CD11b, a neutrophil marker, and the adhesion molecules ICAM-1 and P-Selectin. RESULTS: Extensive infiltration of CD11b-positive cells was detected in venules and capillaries of pancreas allografts after reperfusion (18.38 +/- 0.87) compared with controls (T1 4.22 +/- 0.55) or with tissue specimens at about 10 hours of cold ischemia (2.60 +/- 0.35; P < .001). Similarly, the pattern of P-Selectin showed a moderate expression before organ harvest (1.54 +/- 0.21) and in samples during cold ischemia (1.46 +/- 0.24) followed by a significantly greater number of P-Selectin-positive cells after reperfusion (2.54 +/- 0.18; P = .005). ICAM-1 was only weakly expressed on the surface of the venular endothelium in all controls (0.77 +/- 0.12). In contrast to P-Selectin, ICAM-1 showed prominent up-regulation during cold ischemia (2.23 +/- 0.23; P < .001) with no further increase after reperfusion (2.23 +/- 0.17). CONCLUSION: The data suggested that ICAM-1 was already up-regulated during cold ischemia, possibly representing the mechanism of early neutrophil infiltration observed in human pancreatic ischemia/reperfusion injury.

Islet autotransplantation combined with pancreatectomy for treatment of pancreatic adenocarcinoma: a case report.

Extensive pancreatectomy (EP) may increase the resection rate of pancreatic adenocarcinoma (PA). Unfortunately, EP often results in unstable diabetes. Recently, islet autotransplantation (auto-Tx) has offered the potential to prevent this metabolic disorder. Because of the fear of contamination of prepared islets by malignant cells, this procedure has so far not been used as a treatment for PA. We herein report a case of a 63-year-old nondiabetic patient who underwent EP combined with islet auto-Tx in an emergency operation following histologically proved R(0)-resection for PA (pT(3)pN(1)G(2)). Islets were isolated from the excised pancreas using a continuous digestion filtration device. The resultant preparation was injected into the portal vein. Owing to the moderate fasting hyperglycemia, postoperative exogenous insulin therapy was necessary (26 U/d). After discharge, the patient's daily insulin dose was gradually reduced. At 1-year follow-up the fasting C-peptide level was 0.66 ng/mL, and an oral glucose tolerance test (oGTT) and an intravenous (IV) glucagon stimulation (GS) showed functioning engrafted islets. The K-ras mutations were detected in the paraffin-embedded PA, but not in the prepared islets or in the peripheral blood. Computed tomographic (CT) imaging revealed neither local tumor recurrence nor liver metastases. At 2-year follow-up, the patient was on a balanced food regimen and gaining weight. Although he remains insulin-dependent (16 U/d), he is metabolically stable (HbA(1)(c) 5.9%). The fasting C-peptide level is 0.68 ng/mL. The peak value of C-peptide in response to oGTT was 0.92 ng/mL and to GS 0.89 ng/mL. At this time Ca19-9 and CEA are increased to 35.3 U/mL and 19.2 ng/mL, respectively. The patient died 2.5 years after operation owing to tumor recurrence. There was no evidence for liver metastases. We postulate that histologic evaluation (R(0)-resection) and detection of K-ras mutations may be useful techniques. However, islet auto-Tx after EP for adenocarcinoma should only be regarded for rescue therapy. Studies on strategies to exclude possible contamination of islet tissue with carcinoma cells are critically important.

[Pancreas transplant pathology: clinicopathologic and experimental findings]. / Pathologie der Pankreastransplantation: Klinisch-pathologische und experimentelle Befunde.

134 pancreas transplantations (113 simultaneous pancreas-kidney, 5 pancreas after kidney, 16 pancreas transplants alone) done in Rostock from VI/95 to III/04 were evaluated in respect to pancreas transplant lesions. Additionally, 36 pancreas specimen of Brown Norway rats experimentally transplanted into diabetic Lewis rats were examined. From 55 out of the 134 pancreas transplant patients, 122 partly repeated pancreas graft specimen examinations were carried out morphologically. The principal lesions in the human pancreas transplants were acute (enzymatic) necrotizing transplant pancreatitis (41 samples), acute (13) and chronic (14) transplant rejection specimen as well as primary or secondary graft thrombosis (12 probes). 23 probes were zero-hour biopsies and 2 showed normal tissue. From 69 out of the 118 pancreas transplant patients with an additional kidney graft, a total of 159 renal transplant probes were examined. They showed the following lesions: acute tubular damage or acute renal failure (23), acute (56) or chronic (22) kidney graft rejection, acute tubular cyclosporine or FK 506 toxicity (53), and histologically normal graft tissue (8 cases). As in other grafted organs, the changes occurring in the transplanted pancreas consist of varying lesions related and/or not related to pancreas transplant rejection. A concise classification and a reproduceable grading schedule are suggested for diagnostic, differential diagnostic, therapeutic, and prognostic purposes. Pancreatic rejection lesions can be classified according to a proposed Rostock '04 working classification of pancreas allograft rejection into three grades (I: mild, II: moderate, III: severe) both for acute and chronic pancreas rejection. There was no direct correlation of the findings in 21 patients with simultaneously studied pancreas and renal transplant biopsies. In contrast to renal grafts, pancreatic rejection signs were often superimposed by acute transplantation pancreatitis with or without secondary graft thrombosis, nonenzymatic necroses or infection. Experimental acute pancreas transplant rejection in rats showed quite similar findings to human grafts and was also graded into three different acute rejection stages.

Prilocaine plasma levels and methemoglobinemia in patients undergoing tumescent liposuction involving less than 2,000 ml.

BACKGROUND: As a reaction to reported adverse outcomes after lidocaine infiltration in tumescent liposuction, prilocaine has gained increasing popularity. Previous studies investigating large-volume liposuction procedures found maximum prilocaine levels and methemoglobinemia up to 12 h postoperatively, suggesting that liposuction should be performed as a hospital procedure only. The aim of this study was to determine prilocaine plasma levels and methemoglobinemia in patients after low- to average-volume liposuction for the purpose of defining the required postoperative surveillance period. METHODS: In 25 patients undergoing liposuction involving less than 2,000 ml prilocaine levels and methemoglobinemia were measured over 4 h postoperatively. Liposuction was conducted after the tumescent technique using a 0.05% hypotonic prilocaine solution with epinephrine. RESULTS: The average prilocaine dose was 6.8 + 0.8 mg/kg, with a maximum dose of 15 mg/kg. The peak prilocaine plasma level of 0.34 mug/ml occurred 3 h after the infiltration. The mean methemoglobinemia at this time point was 0.65%. Only one patient demonstrated a slightly elevated methemoglobin level of 1.4%, but lacked any clinical signs of methemoglobinemia. The prilocaine recovery in the aspirate averaged 36 +/- 4%, indicating that a large amount is removed by suctioning. CONCLUSIONS: The patients did not experience high plasma levels of prilocaine or methemoglobinemia undergoing liposuction involving less than 2,000 ml using a 0.05% hypotonic prilocaine solution. The authors therefore conclude that this procedure can be performed safely with a monitoring period of 12 h.

[Successful catheter-guided local thrombolysis in acute pulmonary embolism in the early postoperative period after pancreatic head resection]. / Erfolgreiche lokale Katheterfragmentation und Thrombolyse bei akuter Lungenembolie in der frühen postoperativen Phase nach Pankreaskopfresektion.

Pulmonary embolism in the early postoperative period is characterized by high morbidity and mortality. Systemic application of thrombolytic agents during this time is contraindicated; operative thrombectomy also has a high mortality rate. We report a case of successful local lysis in combination with catheter fragmentation of a massive two-sided pulmonary embolism diagnosed on the 4th postoperative day after pylorus-preserving duodenopancreatectomy for distal carcinoma of the common bile duct. Thrombolysis was performed in three sessions by a combination of catheter-supported interventional fragmentation of the thrombus with local rt-PA lysis. There were no bleeding complications or disturbances of anastomotic healing. The patient was discharged from the hospital on the 23rd postoperative day after changing anticoagulation to a vitamin K antagonist. The case presented demonstrates the possibility of local lysis in combination with interventional methods as a therapeutic option for pulmonary embolism in the early postoperative period as an alternative to surgical strategies.

[Primary aortoduodenal fistula as a late complication of para-aortic radiation therapy. A case report]. / Primäre aortoduodenale Fistel als Spätkomplikation nach paraaortaler Radiatio. Ein Fallbericht.

Primary aortoenteric fistulae (AEFs) are rare vascular entities. More than 75% of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Atherosclerosis, leading to formation of an aortic aneurysm, remains the most common etiology, accounting for more than 3/4 of the cases reported. Primary aortoenteric fistulae following radiotherapy are rare. The case of a 49-year-old man with aortoduodenal fistula 22 years after para-aortic radiation is presented. In November 1997, the patient suddenly developed hematemesis and melena. Endoscopy suggested the presence of an ulcus but no definitive bleeding source could be seen. Bleeding stopped spontaneously. Six hours later he developed massive hematemesis and was transferred to our department. An emergency operation was performed. We found an aorto-duodenal fistula in the third portion of the duodenum without an aortic aneurysm. We directly sutured the aortic wall laceration and resected the third and fourth part of the duodenum. Histology revealed typical signs of radiation damage. The patient is alive and well 2 years after surgery. To our knowledge, this is the sixth case of a primary aorto-duodenal fistula following radiotherapy ever to be reported in world literature.

Low frequency of p53 and ras mutations in bile of patients with hepato-biliary disease: a prospective study in more than 100 patients.

The diagnosis of biliary disease, namely malignant disorders, is frequently hampered by the inconclusive cytology. We investigated prospectively the frequency of molecular changes in p53 and ras compared with cytology in patients with primary or secondary hepato-biliary disease. We investigated 118 consecutive patients, aged 24-89 with the following clinical diagnoses: choledocho/cholecystolithiasis (28), cholangiocellular carcinoma (21), gall bladder tumor (8), liver metastasis (3), autoimmune disease (8), chronic pancreatitis (16), pancreatic carcinoma (11), papillary disease (4), hepatic cirrhosis (6), cholangitis (2), anomalies (2), and normal (9). Bile was aspirated during routine endoscopic retrograde cholangio pancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). DNA was prepared freshly from a native aliquot. p53 mutations were detected by polymerase chain reaction (PCR) for exons 5 through 8 followed by TGGE. PCR for ras mutations was performed as RFLP-PCR with sequencing. In four cases, mutations in p53 could be found in exons 6 and 7. Twenty-two samples showed ras mutations; ras mutations were found in choledocholithiasis (4/28), bile duct (5/21), gall bladder (3/8) and pancreatic (1/11) carcinoma, liver metastasis (3/3), ulcerative colitis (2/3), PSC (1/2), and chronic pancreatitis (1/16). Cytology was clearly positive in seven cases, suspicious in three other, inconclusive in six, and negative in the rest. The molecular analysis resulted in a sensitivity of 33% and specificity of 87%, respectively, for the diagnosis of a malignant condition. PCR for p53 and ras mutations may aid the diagnosis of primary and secondary (metastatic) hepatobiliary disease if a malignant condition of the bile ducts and the liver is suspected and cytology is inconclusive or negative. However, the incidence of p53 and ras mutations in bile seems less frequent than in other malignant conditions of the gastrointestinal tract and the pancreas and lower than in tissue, leaving a poor sensitivity and specificity. Nevertheless, the presence of a p53 and/or ras mutation per se supports a clinical suspicion of malignancy, even when the conventional cytology is negative or inconclusive.

Immortalized pancreatic duct cells in vitro and in vivo.

Although pancreatic adenocarcinoma has become one of the best characterized malignant diseases, severe diagnostic and therapeutic problems are still associated with this disease. The establishment of a molecular model of pancreatic carcinogenesis may provide tools that could result in earlier diagnosis of this disease and, in turn, improves prognosis. Since pancreatic adenocarcinoma seems to originate in epithelial cells in the pancreatic ducts, cultivation of native pancreatic duct epithelial cells (PDEC) is the initial step in the establishment of an in vitro model of pancreatic carcinogenesis. As these native cells survive only a short period in culture, the aim of this study was to establish a stable pancreatic duct cell line by immortalization with the SV40 large T antigen. Furthermore, initial steps in pancreatic carcinogenesis should possibly be imitated by additional transfections of mutated ki-ras and/or mutated p53 genes. By optimization of the isolation protocol and the culture medium, yield as well as proliferative activity of isolated PDEC was increased considerably. Transfection of SV40 large T antigen resulted in an increase in the proliferative lifetime of the isolated cells, but no real immortal phenotype was obtained. Moreover, one step in the transformation from the normal to the malignant phenotype was imitated successfully by additional transfection of mutated ki-ras.

First clinical application of a newly developed device for intragastric surgery for the treatment of pancreatic pseudocysts.

BACKGROUND: Instruments that have been used during GI endoscopy have always been confined to the accessory channel of the endoscope. We have therefore developed a device that allows transabdominal manipulation in the stomach under gastroscopic control. Here we report the first clinical application of this device, which was used for the drainage of pancreatic pseudocysts. METHODS: The device is similar to a PEG tube and consists of a 7 mm polyethylene tube that is inserted by the "thread pull through" method. A trocar valve is mounted at the external tip of the tube. Four pseudocysts were treated in three patients. The retrogastric pseudocysts were punctured through the device under endoscopic (n = 2) and CT (n = 2) guidance. External drainage was used for 3 to 5 days; thereafter the drain was cut and internalized. The device was also cut and sealed. After 10 days it was removed as with a standard PEG tube. RESULTS: No complications related to the device occurred. In two patients the pseudocysts resolved completely. One patient had to undergo pseudocystojejunostomy for an infected pseudocyst containing large amounts of necrotic material. CONCLUSIONS: We believe that our new device is valuable to the further development of intragastric surgery and can be used to safely perform pseudocystogastrostomy.

The nitric oxide donor sodium nitroprusside is protective in ischemia/reperfusion injury of the pancreas.

BACKGROUND: The role of nitric oxide in the ischemia/reperfusion injury of the pancreas is still unclear. In other organs, protective as well as aggravating effects have been described. We have, therefore, investigated the effect of the nitric oxide donor sodium nitroprusside on pancreatic ischemia/reperfusion injury. METHODS: In Landrace pigs, after transsection of the pancreas, complete vascular isolation of the pancreatic tail was performed. The tail was subjected to 3 hr of warm ischemia and thereafter reperfusion (6 hr). The animals were divided into a control group (n=7) and a treatment group (n=7) that received 15 mg of sodium nitroprusside after reperfusion intra-arterially into the splenic artery. RESULTS: The morphological tissue damage and lipase activity in the venous effluent of the pancreas were significantly lower in the treatment group. Partial oxygen tension in the tissue after reperfusion was markedly reduced in the control group, indicating an impairment of microcirculation. In the treatment group, however, partial oxygen tension in the tissue was significantly higher (43 vs. 20 mmHg; P<0.014). Furthermore, total blood flow through the pancreatic tail in the treatment group was found to be significantly higher in the late reperfusion period (14 vs. 9.5 ml/min at 5 hr after reperfusion; P<0.05). CONCLUSION: There is a marked impairment of pancreatic microcirculation after reperfusion. Sodium nitroprusside counteracts this impairment and has a protective effect on ischemia/reperfusion injury of the pancreas.