Transhepatic intravascular ultrasound for evaluation of portal venous involvement in patients with cancer of the pancreatic head region.

The aim of this study was to evaluate the ability of intravascular ultrasound to diagnose tumor involvement of the portal and the superior mesenteric veins using the preoperative percutaneous, transhepatic approach, and to compare the findings with those made at concomitant direct portography, surgery, and histopathological examination. Ten patients with a preoperative diagnosis of a resectable tumor in the pancreatic head region were examined with percutaneous transhepatic portography (PTP) and intravascular ultrasound (IVUS). The surgeon's intraoperative evaluation and the histopathological examination in combination revealed tumor involvement of the portal or superior mesenteric veins in six of the ten patients. Percutaneous transhepatic portography suggested tumor involvement of the veins in six patients but two of the examinations were false positive and another two were false negative. Intravascular ultrasound showed signs of tumor involvement in eight patients. The examination was, however, false positive in two patients, but there were no false negatives. Complications of the percutaneous transhepatic procedure occurred in six patients including severe pain, bleeding, and related death. Percutaneous transhepatic IVUS of the portal vein may be a useful tool in the preoperative selection of the subgroup of patients with tumor of the pancreatic head region that could benefit from surgery. There is a need for technical improvement as well as studies with larger patient series to definitely decide the role of the technique.

Congenital absence of the intrahepatic portion of the portal vein in an adult male resected for hepatocellular carcinoma.

We report a case of congenital absence of the portal vein (CAPV) in an adult male who underwent resection for hepatocellular carcinoma. CAPV is a rare anomaly; only 29 cases, mostly in children, have been presented to date. An association between CAPV and cardiac abnormalities, polysplenia syndrome, skeletal abnormalities and liver tumors has been seen in children. To the best of our knowledge this is the first case of CAPV in an adult male resected for hepatocellular carcinoma. However, since CAPV can be without symptoms, the number of undiagnosed cases is not known.

[Guidelines for management of patients with acute pancreatitis]. / Riktlinjer för handläggning av patienter med akut pankreatit.

During recent years new concepts and methods have been introduced in the management of acute pancreatitis. Severity and risk of complications show wide variation. Outcome is also dependent on the physician's experience and on his local resources. In this light the Swedish Society of Upper Abdominal Surgery has elaborated national guidelines for management. Attention is paid to diagnosis, severity assessment and etiology. Furthermore, guidelines are offered for treatment of mild and severe pancreatitis, as well as for the management of pseudocysts. The role of multidisciplinary intensive care specialist teams in the management of severe disease is emphasized. The guidelines are supported by the Swedish Society of Gastroenterology, the Swedish Society of Gastroenterology, the Swedish Society of Anesthesiology and Intensive Care and by experts from other Nordic countries.

Serous and mucinous cystadenoma/cystadenocarcinoma of the pancreas.

Twenty cases of cystic pancreatic neoplasms were examined over a 10-year period by the Department of Radiology, University Hospital, Lund, Sweden. Four patients had serous cystadenoma, seven had mucinous cystadenoma, and seven had mucinous cystadenocarcinoma. One patient had a mucin-producing ductal carcinoma, and one patient had a benign mucus cyst. The various types of tumor are illustrated, and the difficulty in differentiating the subtypes is stressed.

Dearterialization of colorectal liver cancer: institutional experience.

BACKGROUND/AIMS: Preliminary clinical trials have suggested that dearterialization (interruption of arterial blood supply) is beneficial to patients with liver tumours. The aim of this report was to review the outcome of all patients undergoing dearterialization for colorectal liver metastases and to analyze whether refinement of the technique was followed by improvement in outcome. METHODS: Retrospective review of 57 patients undergoing temporary (16 h) dearterialization during 1972-1984 (n = 24) or repeated transient dearterialization (1-2 h once or twice daily) during 1985-1995 (n = 33). RESULTS: The median survival after start of treatment was 1.1 years, and the 5-year survival rate was 0%. There was no significant difference in survival between temporary and repeated transient dearterialization. Liver tumour volume and extrahepatic metastases varied negatively with survival. The temporary dearterialization procedure was followed by hepatic or intra-abdominal abscess formation in 6 patients (24%), leading to postoperative death in 2 patients (operative mortality 8%). Complications after repeated transient dearterialization were related mainly to technical problems with the occluder device. CONCLUSION: Although this was not a randomized study, it appears that dearterialization is of no benefit in colorectal liver cancer.

Jejunal loop obstruction at the ligament of Treitz: a distinct radiological and clinical picture of recurrence after subtotal pancreatectomy.

Of 99 patients operated on with subtotal pancreatectomy due to ampullary carcinoma, five had a local recurrence in the pancreatic bed at the ligament of Treitz. The patients all had distinct symptoms: recurrent bouts of fever, general malaise, and rapid loss of weight. They had little pain, but all were jaundiced in spite of absence of marked compression of the bile ducts. Computed tomography or ultrasound could not detect the small, local recurrence that was obstructing the jejunal loop 10-15 cm distal to the hepaticojejunostomy, but as an indirect sign of the recurrence, the distended small bowel loop proximal to the ligament of Treitz was clearly seen in all patients.

Intraluminal duodenal diverticulum causing pancreatitis in a patient with a polysplenia syndrome.

A 19-year-old female had recurrent bouts of pancreatitis. At endoscopy a mucosa-covered mass lesion was seen in the duodenum. A double-contrast examination of the stomach and duodenum showed an intraluminal duodenal diverticulum (IDD). Also an inversed abdominal situs and a midgut malrotation were noted. Computed tomography revealed evidence of a polysplenia syndrome. Although this syndrome is associated with various gastrointestinal abnormalities, its combination with an IDD does not seem to have been reported previously. After surgical removal of the IDD the patient has not had any further attacks of pancreatitis.

[Influenza vaccination of the elderly in the municipality of Copenhagen]. / Influenzavaccination af aeldre i Københavns Kommune.

In October/November 1996 all people living in the city of Copenhagen aged 70 and above were invited to receive an influenza vaccination. Of a total of 62,600 people, 35,423 were vaccinated which is a participation rate of 56%. The participation rate increased with increasing age and in the older age groups the participation rate was 80%. The vaccinations were performed by nurses and most of the participants were vaccinated in special clinics (74.9%). Immobile participants were vaccinated either in their own homes (14.3%), in nursing homes (9.2%), or in hospitals (1.6%). One single case of hospitalisation of a chronically ill patient was registered, because of a weak influenza. No other side effects were registered. The total cost of all vaccinations was 4 million dkr. which is 115 dkr. (approximately 10 Pounds sterling) for each vaccination.

Computed tomography and laparoscopy in the assessment of the patient with pancreatic cancer.

BACKGROUND: In most patients with pancreatic cancer, the tumor is unresectable. Nonoperative methods for palliation of jaundice, duodenal obstruction, and pain currently are being developed. Preoperative assessment of resectability of the tumor is becoming more and more important to avoid unnecessary operations. The aim of this study was to compare computed tomography (CT) and laparoscopy with special reference to the additive role of the latter technique in predicting unresectability of pancreatic cancers. STUDY DESIGN: Sixty patients with exocrine pancreatic cancer were assessed prospectively with both CT and laparoscopy. On the basis of metastatic spread or signs of vascular involvement, the radiologist and the laparoscopist independently reported the tumors as probably unresectable or resectable. RESULTS: The predictive value for unresectability was 100% for both CT and laparoscopy. Sensitivity in predicting unresectability was 69% for both techniques, and the corresponding figure for specificity was 100%. When CT and laparoscopy were evaluated together, an improvement in sensitivity to 87% was observed (p < 0.05). Separately, CT and laparoscopy correctly predicted resectability in only 30% and 38% of the patients, respectively. The presence of liver metastases was overlooked by CT in 13 of 32 patients (40%). Every fourth patient who was found to have unresectable tumor at CT was falsely classified as resectable by the laparoscopist, leading to unnecessary laparotomies. On the other hand, 9 of 24 patients (38%) with resectable disease at CT were deemed unresectable at the subsequent laparoscopy. CONCLUSIONS: Laparoscopy and CT independently and reliably predicted unresectability of pancreatic cancer, but the methods were inaccurate in forecasting resectability. The results suggest that CT examination should be done in patients who are candidates for attempted curative surgical procedures, whereas laparoscopy should be restricted to Those Judged resectable at CT.

Cholangiographic appearance of bile-duct cysts.

Bile-duct cysts or congenital bile-duct dilatation are rare but important abnormalities often mimicking calculous biliary tract disease. Bile-duct cysts are most often classified according to Todani. In a retrospective study of percutaneous, peroperative or endoscopic cholangiograms from 25 patients, diagnosed and treated during a 20-year period, images of different types of bile-duct cysts are presented and classified. The disease usually presents with vague symptoms and has a female preponderance. Current opinion on aetiology and complications is discussed. Cholangiography is a necessary prerequisite to surgical therapy.

Intravascular ultrasound for evaluation of portal venous involvement in pancreatic cancer.

The aim of this study was to evaluate the accuracy of intravascular ultrasound (IVUS) in diagnosing tumour involvement of the portal vein in patients with exocrine cancer of the head of the pancreas. Seven consecutive patients with a preoperative diagnosis of carcinoma, preoperatively deemed to be resectable, were examined with IVUS of the portal vein during surgery. The IVUS catheters were 6.2 F (2.0 mm) in diameter with a 20-MHz transducer and were introduced into the portal vasculature through the mesenteric superior vein. All patients had tumour extending to the portal vein as demonstrated at histopathological examinations in six cases and at surgical dissection in one case. The IVUS technique correctly identified all these patients, whereas five patients were incorrectly deemed at surgery not to have tumour involvement of the portal vein. These results indicate that IVUS is a very sensitive method for the evaluation of tumour involvement of the portal vein.