Pancreaticoduodenectomy with preoperative total embolization of the hepatic arteries (PD-HAE)-a novel treatment with sacrifice of the hepatic arterial blood supply without the need for arterial reconstruction.

PURPOSE: Tumors with involvement of common hepatic and gastroduodenal arteries (CHA and GDA) or GDA and the proper hepatic artery (PHA) are traditionally considered nonresectable. We have devised a new procedure that includes pancreaticoduodenectomy with preoperative hepatic artery embolization (PD-HAE) to facilitate an R0 resection of tumors involving the hepatic arteries without vascular anastomoses and complete sacrifice of normal hepatic arterial blood supply. METHODS: To allow resection of the hepatic arteries, preoperative embolization of the PHA was performed to induce an increased collateral arterial blood flow from the periphery of the liver, far from the hepatic hilum 10-14 days prior to the operation. Between May 1, 2017 and December 31, 2019, eight patients with ductal adenocarcinoma were operated with the PD-HAE procedure. RESULTS: The embolizations were uneventful apart from a transient marginal elevation of alanine aminotransferase in three patients. All patients had N disease with perineural invasion of tumor cells around the adventitia of the artery and severe perivascular inflammation. An R0 resection (> 1.0 mm to all resection margins) was obtained in six patients (75%). Mean hospital stay was 12 days. Median survival was 23 months (95% CI: 19.5-26.5 months). Six patients (75%) are still alive 11 to 36 months after the operation. There was perioperative fatality, and morbidity was comparable to standard pancreaticoduodenectomy. CONCLUSION: PD-HAE is a safe procedure and may provide the opportunity for curative resection in otherwise unresectable patients. However, larger studies are needed to evaluate this procedure.

Distal pancreas-coeliac axis resection with preoperative selective embolization of the coeliac axis: a single high-volume centre experience.

BACKGROUND: Patients with ductal adenocarcinoma in the body and/or tail of the pancreas with involvement of the common hepatic artery and/or celiac axis have until recently been considered unresectable. In selected cases, distal pancreatectomy (DP) with en bloc celiac axis resection (DP-CAR) may be an option to achieve R0 resection. METHODS: Patients with tumours in the body and/or tail of the pancreas locally advanced with involvement of the common hepatic artery and/or celiac axis, with no distant metastases, were evaluated for DP-CAR procedures. Preoperative embolization was performed 10-14 days prior to surgery to enhance collateral arterial supply for the liver and stomach. RESULTS: A total of 21 patients went through DP-CAR of whom 15 were preoperatively embolized. R0 resection vas achieved in 76% of the patients comparable to our standard distal pancreatectomies. The DP-CAR patients had a significant longer postoperative hospital stay, but no difference in major complications, including pancreatic fistulas compared with our standard distal pancreatectomies. No 30 nor 90 days postoperative mortality were recorded. Median survival in patients who underwent DP and DP-CAR procedures was 24.0 and 23.5 months, respectively (P > 0.5). CONCLUSION: Outcomes after DP-CAR are comparable to standard distal pancreatectomies. DP-CAR after preoperative embolization is feasible and may in selected patients be a good option for treating patients with tumours in the body and/or tail of the pancreas with central arterial involvement.

Postoperative and long-term survival in relation to life-expectancy after pancreatic surgery in elderly patients (cohort study).

BACKGROUND: An evaluation of the outcome after pancreatic surgery with focus on post-operative and late survival in elderly patients was performed. METHODS: The study included 1.556 patients from a single HBP unit operated from 1. January 2010 to 31. December 2019. Patients were divided into two cohorts, < 75 years (n = 1.296) and ≥75 years (n = 260). Post-operative outcome was evaluated in all patients and late outcome in patients with adenocarcinoma in the pancreas (n = 765) and the duodenum (n = 117). The follow-up of patients with benign disease and adenocarcinoma was 57.95 (12.1-132.7) and 39.85 (12.0-131.7) months, respectively. RESULTS: Length of hospital-stay and surgical complications were not significantly different in the two cohorts, but in-hospital death was 1.1% (<75 years) and 3.5% (≥75 years) (p = 0.008). The median overall survival of adenocarcinoma was 29.7 (<75 years) and 24.3 months (≥75 years) (p = 0.3228) with a one, two, and five-years survival of 74.5%, 56.6% and 28.6% vs. 73.6%, 51.1%, and 25.5%. Median time to relapse (46.2% of patients <75 years and 40.5% of patients ≥75 years) was 9 (1 - 51) and 8 (1 - 78) months (p = 0.534), respectively. Adjuvant chemotherapy did not have impact on the survival of the old cohort. Patients who died during the observation period had lost 94% (<75 years) and 87% (≥75 years) of expected remnant life. Estimated years lost in the old cohort was 4.2 in males and 4.9 in females (p = 0.025). CONCLUSION: Elderly patients may undergo pancreatic surgery with a low mortality and for adenocarcinoma with an acceptable long-term survival.

Interventional treatment of neuroendocrine liver metastases.

Neuroendocrine gastroenteropancreatic tumours are rare with an incidence of 2-4/100.000 per year. More than 75% of the patients develop hepatic metastases, which reduce the five year survival from 70-80% to 30-40%. In addition to chemo- and biotherapy, interventional therapy of liver metastases should be considered in order to prolong survival and reduce endocrine and local symptoms. Surgical resection is the only curative treatment, but possible in less than 10% of the patients. Curative and palliative resection, which is possible in less than 20-25% of the patients, relieve endocrine and local symptoms in 90% of the patients for more than two years, and the five year survival is prolonged to 40-85%, although metastases recur or progress in almost all patients. Tumour ablation by radiofrequency therapy has a palliative effect on endocrine symptoms in 70-90% of the patients for up to two years, but should not be a substitute for surgical treatment. When metastases are not eligible for surgical treatment or ablation, embolization or chemoembolization are alternative options with a reduction in tumour burden in about 50% and a five year survival of around 60% ofthe patients. The symptomatic response rate is 90% with a mean duration of two years. Liver transplantation should be restricted to very few and highly selected patients without extrahepatic disease. Recurrence is inevitable in nearly all patients.

The occurrence of Enterococcus faecium and faecalis Is significantly associated With anastomotic leakage After pancreaticoduodenectomy.

BACKGROUND AND AIMS: Enterococcus has emerged as a virulent species; Enterococcus faecium especially has arisen as a source of nosocomial infections. Furthermore, specific Enterococcus faecalis species are significantly associated with anastomotic leakage in rodent studies. The objective of this study was to investigate whether the occurrence of Enterococci ( E. faecium and E. faecalis) obtained from drain samples was associated with leakage in humans undergoing pancreaticoduodenectomy. MATERIALS AND METHODS: All patients undergoing pancreaticoduodenectomy had a peritoneal drain sample sent for culturing between postoperative days 3 and 10. Postoperative pancreatic fistulas were defined and classified according to the International Study Group of Pancreatic Fistula. Bile leakage was radiologically verified. Postoperative complications were classified according to the Dindo-Clavien classification. RESULTS: A total of 70 patients were eligible and enrolled in this study. Anastomosis leakage was observed in 19 patients; 1 leakage corresponding to the hepaticojejunostomy and 18 pancreatic fistulas were identified. In total, 10 patients (53%) with leakage had Enterococci-positive drain samples versus 12 patients (24%) without leakage [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 1.4-19.4, p = 0.02]. Preoperative biliary drainage with either endoscopic stenting or a percutaneous transhepatic cholangiography catheter was associated with the occurrence of Enterococci in drain samples (OR = 5.67, 95% CI = 1.8-12.9, p = 0.003), but preoperative biliary drainage was not associated with leakage (OR = 0.45, 95% CI = 0.1-1.7, p = 0.23). CONCLUSION: Enterococci in drain sample cultures in patients undergoing pancreaticoduodenectomy occurs significantly more among patients with anastomotic leakage compared to patients without leakage.

Adherence to a healthy Nordic food index and risk of myocardial infarction in middle-aged Danes: the diet, cancer and health cohort study.

BACKGROUND/OBJECTIVES: For decades, the Mediterranean diet has been in focus regarding healthy eating as it has been associated with reduced risk of non-communicable diseases. Less interest has been given to health benefits of other regional diets. The aim of the present study was to assess whether adherence to a healthy Nordic food index was associated with lower risk of myocardial infarction (MI) among middle-aged Danes. SUBJECTS/METHODS: Data were obtained from the Danish Diet, Cancer and Health cohort study of 57 053 men and women aged 50-64 years recruited between 1993 and 1997. The healthy Nordic food index comprised healthy Nordic food items selected a priori (fish, cabbage, rye bread, oatmeal, apple and pears and root vegetables). Information on incident MI was ascertained through linkage with national registries. Hazard ratios (HR) with 95% confidence intervals (CI) were estimated from sex-specific Cox proportional hazard models. RESULTS: In total, 1669 men and 653 women developed MI during follow-up (13.6 median years). In adjusted models, those with an index score of 5-6 points (highest scores) had significantly lower MI risk (men: HR=0.77, 95% CI=0.62, 0.97; women: HR=0.55, 95% CI=0.37, 0.82) relative to those scoring 0 points in the index (lowest score). A significantly lower MI risk was found per 1-point increment in the index in both men (HR=0.95, 95% CI=0.92, 0.99) and women (HR=0.93, 95% CI=0.88, 0.98). CONCLUSIONS: A healthy Nordic diet is associated with lower MI risk among middle-aged Danes, suggesting that Nordic diets should be considered in recommendations for dietary changes in the promotion of coronary health.

Glucose homeostasis after orthotopic liver transplantation in the pig.

Plasma glucose, insulin, and C-peptide were measured in seven pigs after intravenous bolus injection of 1 mg glucagon and injection of 15 g glucose on the 1st, 2nd, 4th, and 7th days after orthotopic liver transplantation. Fasting plasma glucose and the glycemic response to glucagon were lower at the first postoperative day than on any other day (P less than 0.05). Glucose clearance after injection of glucose was normal and without day-to-day variation. Plasma insulin and C-peptide concentrations were higher the first day after glucose stimulation (P less than 0.05), but no impairment of insulin secretion was found during the study. We conclude that, apart from low hepatic glucose production on the first postoperative day, glucose homeostasis was sufficient after liver transplantation.

Pulmonary hamartoma.

Eighty-nine cases of pulmonary hamartoma were studied. There were 51 men and 38 women, with a mean age of 57.5 years (range 14 to 76 years). A histologic diagnosis from examination of the resection specimens was obtained in all patients who had operations. Moreover, transthoracic needle aspiration biopsies were performed in 40 patients, with a diagnostic result in 34 (85%). The hamartomas were equally distributed in the pulmonary lobes; mean transverse diameter at the time of diagnosis was 21.7 +/- 16.2 mm. Tumor size was independent of the anatomic localization, but it correlated with the age of the patients (p less than 0.01). Tumor growth was recorded in 15 of 31 patients who had follow-up (45%); mean expansion in transverse diameter was 3.2 +/- 2.6 mm per year during an average observation time of 4.1 years (range 1 to 20 years). Pulmonary symptoms were present in 35 patients (39%). Seventy-five patients underwent operations as follows: enucleation (54), resection (11), lobectomy (5), pneumonectomy (4), and bronchoscopic removal (1). Since most pulmonary hamartomas are nonexpanding or slowly growing neoplasms, it is concluded that operation is necessary only when expansion is recorded in young or middle-aged patients and in patients with pulmonary symptoms.

Does survival depend on the amount of autotransplanted splenic tissue?

Susceptibility to Streptococcus pneumoniae infection was studied in 11 groups of rats allocated to sham operation, splenectomy, or splenic autotransplantation of 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% of the removed spleen. Three months later, all rats were exposed intravenously to type 1 Streptococcus pneumoniae (median lethal dose, LD50, for control group). Survivors were killed 13 days after the bacterial challenge. Autopsy showed that more splenic tissue was recovered in rats that received less than 50% splenic tissue compared with those that received 50% or more. More survivors were found among sham-operated rats (47.5%; 95% confidence intervals, 32 to 68) and rats that had 40% splenic tissue implanted (35%; confidence interval, 20 to 54) or those that were found to have regenerated 40% splenic tissue. We conclude that 40% of the spleen should be autotransplanted to protect the rat optimally against infection after splenectomy.

Phagocyte function after splenic autotransplantation.

This study was designed to examine the role of splenectomy and autotransplantation with regard to the leukocyte/differential cell counts and the function of peripheral blood phagocytes. Eleven groups of 40 Wistar male rats in each group either underwent total splenectomies or sham operations. The splenectomized groups underwent autotransplantations with 10% through 90% of the weight of the intact spleen. The leukocyte count and the oxidative burst response of the blood leukocytes were measured in each group. It was shown that a total splenectomy did not alter the leukocyte/differential cell counts. Furthermore, the blood picture remained basically unchanged after an autotransplantation with 10% through 90% of the weight of the intact spleen. The phagocyte oxidative burst response was measured by chemiluminescence. The chemiluminescence response of these cells was reduced after a total splenectomy. The phagocyte oxidative burst response returned to normal levels following an autotransplantation. There was no correlation between the amount of autotransplanted spleen and the degree of the oxidative burst response. These findings indicated that a splenectomy results in a diminished phagocyte oxidative burst response and that a spleen autotransplantation returns this function to normal levels.

Stereotypies in ranch mink: the effect of genes, litter size and neighbours.

This study was conducted on two generations of ranch mink to test the hypothesis that the behaviour of stereotypy (SY) in ranch mink is subject to heredity. Two groups of 14 females were selected as low stereotyping and high stereotyping individuals as extremes from 61 females. They were observed in two periods, one before mating and one after mating. The selection was based upon four SY frequencies of which two excluded the parameter Pendling. The kits of the two groups of females were also observed and the difference in level of SY between the two groups of mothers was upheld in the next generation. Combined with the finding of a positive, though not significant, correlation between the SY frequency of mothers and the mean frequency of litters this indicated a genetic effect upon the level of SY. A positive correlation between the litter size and the mean SY level of the litters was found. Though not significant it was considered important. A neighbour effect on the SY level in farm mink could not be found. All these results were obtained regardless of whether or not Pendling was incorporated into the SY frequency indicating that Pendling is induced by the same factors as other SYs.

[Perioperative administration of recombinant human erythropoietin in colorectal cancer surgery. A prospective, randomized, double-blind placebo controlled study]. / Perioperativ administration af rekombinant human erytropoietin ved kirurgi for kolorektal cancer. Et prospektivt, randomiseret, dobbeltblindet placebokontrolleret studium.

One hundred patients scheduled for elective colo-rectal cancer surgery, and with a preoperative haemoglobin level < or = 8.5 mmol/l were included. Eighty-one patients could be evaluated. Thirty-eight patients received r-HuEPO in a dose of 300 IU/kg body weight on day four before surgery and 150 IU/kg, daily, for the following seven days, and 43 patients received placebo. In addition, all patients received daily doses of 200 mg iron, orally, for four days before surgery. On the day of surgery and until discharge the haemoglobin concentration was significantly higher in the erythropoietin group compared to the placebo group. The number of blood transfusions given was significantly lower in the erythropoietin group with a mean of 0.3 units per patient (0-6) compared to 1.6 units (0-9) in the control group (p < 0.05). The clinical implications of these findings has yet to be assessed.

Intake of ruminant trans fatty acids and changes in body weight and waist circumference.

BACKGROUND/OBJECTIVES: Follow-up studies have suggested that total intake of trans fatty acids (TFA) is a risk factor for gain in body weight and waist circumference (WC). However, in a cross-sectional study individual TFA isomers in adipose tissue had divergent associations with anthropometry. Our objective was to investigate the association between intake of TFA from ruminant dairy and meat products and subsequent changes in weight and WC. Furthermore, potential effect modification by sex, age, body mass index and WC at baseline was investigated. SUBJECTS/METHODS: Data on weight, WC, habitual diet and lifestyle were collected at baseline in a Danish cohort of 30,851 men and women aged 50-64 years. Follow-up information on weight and WC was collected 5 years after enrolment. The associations between intake of ruminant TFA (R-TFA) and changes in weight and WC were analysed using multiple linear regression with cubic spline modelling. RESULTS: Intake of R-TFA, both absolute and energy-adjusted intake, was significantly associated with weight change. Inverse associations were observed at lower intakes with a levelling-off at intakes >1.2 g/day and 0.4 energy percentage (E %). Absolute, but not energy-adjusted, intake of R-TFA was significantly associated with WC change. An inverse association was observed at lower intakes with a plateau above an intake of 1.2 g/day. CONCLUSIONS: The present study suggests that intake of R-TFA is weakly inversely associated with changes in weight, whereas no substantial association with changes in WC was found.

Evaluation of contrast-enhanced ultrasound of the pancreas combined with concurrent hormone stimulation.

PURPOSE: To evaluate the potential of combined administration of the gastrointestinal hormones secretin (Secrelux) and c-terminal cholecystokinin (CCK-8 s) together with contrast-enhanced ultrasound (CE-US) to generate an extended contrast enhancement of healthy pancreatic tissue. MATERIALS AND METHODS: 14 anaesthetised pigs weighing 30-35 kg were studied. After laparotomy, the pancreas was located and a B-mode examination followed by a CE-US examination of the gland was made using SonoVue 1.5 ml. After an injection of Secrelux 1 U/kg and CCK-8 s 100 pmol/kg, a second CE-US examination was conducted. The hormones and the contrast agent were administered through a catheter in the superior vena cava. The sonographic images were stored for later evaluation. RESULTS: The study showed that CE-US increased the echogenicity of the pancreas by an average of 15.6 decibel (dB) (confidence intervals [CI]: 13.72, 17.42) p < 0.0001, an increase of 24%. The administration of Secrelux and CCK-8 s in combination with CE-US further increased the echogenicity of the pancreas by an average of 3% (CI: 0.36, 5.36) p = 0.028. A new sequence of hormones and CE-US 20 min after the previous injection did not induce further enhancement. The area under the curve (AUC) was significantly larger using both hormones and CE-US compared with CE-US alone by an average of 66 dBx sec (CI: 28,103) p = 0.002. CONCLUSION: It is possible to generate an extended contrast enhancement of healthy pancreatic tissue using CE-US combined with the administration of the gastrointestinal hormones secretin (Secrelux) and c-terminal cholecystokinin (CCK-8 s). Our results may improve the ability to discriminate between healthy pancreatic tissue and areas with a changed blood flow due to either neoplasm or other pathological lesions.

Interstitial deletion of chromosome 4p associated with mild mental retardation, epilepsy and polymicrogyria of the left temporal lobe.

In this study, we present a 38-year-old woman with an interstitial deletion of 4p15.1-15.3, mild mental retardation, epilepsy and polymicrogyria adjacent to an arachnoid cyst of the left temporal lobe. The deletion was ascertained through array-comparative genome hybridization screening of patients with epilepsy and brain malformations. To date, about 35 patients with cytogenetically visible deletions involving 4p15 and without Wolf-Hirschhorn syndrome have been described, but the extent of the deletions has not been determined in the majority of these cases. The clinical manifestations of the patient described in this study were similar but not identical to the previously reported cases with 4p15 interstitial deletions. This finding indicates the presence of one or more genes involved in brain development and epilepsy in this chromosome region.

Leiomyosarcomas of the gastrointestinal tract.

Nine men and four women (median 69 years, range 38-86 years) with gastrointestinal leiomyosarcomas were treated from 1981 to 1991. Tumours arose from the stomach (5), the small intestine (6) and the rectum (2). Nearly half of all patients were surgical emergencies: one patient had perforation of the stomach and two of the small intestine from tumour ulceration, three cases presented with life-threatening bleeding from leiomyosarcomas of the small intestine. All patients were operated on, but only seven for cure. At follow-up one patient had emigrated and four had died, two from leiomyosarcoma after 13 and 36 months and two from unrelated causes after seven and 48 months. Two patients are still alive 24 and 78 months after surgery without recurrence. Patients and amenable to a curative operation died within nine months.