Are There Indications for Total Pancreatectomy in 2016?

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.

Surgical decision-making in acute appendicitis.

BACKGROUND: Acute appendicitis is one of the most common acute abdominal conditions. Among other parameters, the decision to perform surgical exploration in suspected appendicitis involves diagnostic accuracy, patient age and co-morbidity, patient's own wishes, the surgeon's core medical values, expected natural course of non-operative treatment and priority considerations regarding the use of limited resources. Do objective clinical findings, such as radiology and laboratory results, have greater impact on decision-making than "soft" clinical variables? In this study we investigate the parameters that surgeons consider significant in decision-making in cases of suspected appendicitis; specifically we describe the process leading to surgical intervention in real settings. The purpose of the study was to explore the process behind the decision to undertake surgery on a patient with suspected appendicitis as a model for decision-making in surgery. METHODS: All appendectomy procedures (n = 201) at the Department of Surgery at Karolinska University Hospital performed in 2009 were retrospectively evaluated. Every two consecutive patients seeking for abdominal pain after each case undergoing surgery were included as controls. Signs and symptoms documented in the medical records were registered according to a standardized protocol. The outcome of this retrospective review formed the basis of a prospective registration of patients undergoing appendectomy. During a three- month period in 2011, the surgeons who made the decision to perform acute appendectomy on 117 consecutive appendectomized patients at the Karolinska University Hospital, Huddinge, and Södersjukhuset, were asked to answer a questionnaire about symptoms, signs and diagnostic measures considered in their treatment decision. They were also asked which three symptoms, signs and diagnostic measures had the greatest impact on their decision to perform appendectomy. RESULTS: In the retrospective review, tenderness in the right fossa had the greatest impact (OR 76) on treatment decision. In the prospective registration, the most frequent symptom present at treatment decision was pain in the right fossa (94 %). Tenderness in the right fossa (69 %) was also most important for the decision to perform surgery. Apart from local status, image diagnostics and blood sample results had the greatest impact. CONCLUSION: Local tenderness in the right fossa, lab results and the results of radiological investigations had the greatest impact on treatment decision.

High dietary glycemic load increases the risk of non-gallstone-related acute pancreatitis: a prospective cohort study.

BACKGROUND & AIMS: Obesity and type 2 diabetes--diseases linked to glucose intolerance and insulin resistance--have been positively associated with the risk of acute pancreatitis. However, it is unclear whether consumption of foods that increase postprandial glycemia and insulinemia have similar associations. We examined the association between dietary glycemic load and risk of non-gallstone-related acute pancreatitis. METHODS: We performed a prospective study of 44,791 men and 36,309 women (aged 45-84 years), without a history of acute pancreatitis, from the Cohort of Swedish Men and the Swedish Mammography Cohort. Glycemic loads were calculated from food frequency questionnaire data collected in 1997, and participants were followed for the development of non-gallstone-related acute pancreatitis through 2010 via linkage to the Swedish National Patient Register. Hazard ratios (HRs) were estimated using Cox proportional hazard models. RESULTS: During a total follow-up of 967,568 person-years, there were 364 cases of incident non-gallstone-related acute pancreatitis (236 in men and 128 in women). Incidence rates, standardized for age and sex, were 49 cases per 100,000 person-years in the highest quartile of glycemic load and 33 cases per 100,000 person-years in the lowest. The multivariate-adjusted HR of non-gallstone-related acute pancreatitis was 1.60 (95% confidence interval [CI], 1.17-2.18) for the highest compared with the lowest quartile. Every 50-unit increase in glycemic load per day (∼ 3 servings of white bread) had an HR of 1.38 in men (95% CI, 1.11-1.72) and women (95% CI, 1.02-1.86). CONCLUSIONS: Based on a large, prospective cohort study, diets with high glycemic load are associated with an increased risk of non-gallstone-related acute pancreatitis.

Aspects on gallbladder cancer in 2014.

PURPOSE OF REVIEW: To discuss some key issues involved in the management of gallbladder cancer (GBC). RECENT FINDINGS: The decline in incidence and mortality of GBC began decades before the introduction of laparoscopic surgery. In consecutive autopsies and in cases in which cholelithiasis was present, the incidence of gallbladder carcinoma is 3-4%. A number of genetic alterations have been identified in the different stages of GBC and they support the morphological evidence of two pathways by which tumors develop. Some of these genetic changes are associated with particular risk factors. All management of GBC and all comparisons of treatment results from different centers must be based on the stages. SUMMARY: Simple cholecystectomy is the adequate treatment for T1a GBC. Lymph node excision improved survival in patients with T2 lesions. Radical en bloc resection of T2 tumors offers greater benefit over conventional cholecystectomy alone in terms of greater long-term survival times. Provided that negative surgical margins are secured, hepatectomy and lymph node resection can, therefore, be withheld in most cases in the surgical treatment of pT2 GBC. With improvements in surgical and anesthetic techniques, aggressive surgery has proven to be performed with safety.

Vegetables, fruit and risk of non-gallstone-related acute pancreatitis: a population-based prospective cohort study.

OBJECTIVE: To examine the association of vegetable and fruit consumption with the risk of non-gallstone-related acute pancreatitis. DESIGN: A population-based prospective cohort of 80,019 women and men, aged 46-84 years, completed a food-frequency questionnaire at baseline and was followed up for incidence of non-gallstone-related acute pancreatitis from 1 January 1998 to 31 December 2009. Participants were categorised into quintiles according to consumption of vegetables and consumption of fruit. Cox proportional hazards models were used to estimate RRs and 95% CIs. RESULTS: In total, 320 incident cases (216 men and 104 women) with non-gallstone-related acute pancreatitis were identified during 12 years of follow-up (891,136 person-years). After adjustment for potential confounders, the authors observed a significant inverse linear dose-response association between vegetable consumption and risk of non-gallstone-related acute pancreatitis; every two additional servings per day were associated with 17% risk reduction (RR=0.83; 95% CI 0.70 to 0.98; p=0.03). Among participants consuming >1 drink of alcohol per day and among those with body mass index ≥25 kg/m2, the RR for the highest compared with the lowest quintile of vegetable consumption was 0.29 (95% CI 0.13 to 0.67) and 0.49 (95% CI 0.29 to 0.85), respectively. Fruit consumption was not significantly associated with the risk of non-gallstone-related acute pancreatitis; the RR comparing extreme quintiles of consumption was 1.20 (95% CI 0.81 to 1.78). CONCLUSIONS: Vegetable consumption, but not fruit consumption, may play a role in the prevention of non-gallstone-related acute pancreatitis.

Portal venous system thrombosis after pancreatic resection.

BACKGROUND: Portal venous system thrombosis (PVST) is a rare, potentially fatal complication after pancreatic resection. The aim of this study was to assess the incidence, presenting symptoms, management, and treatment of PVST in a large cohort of patients. METHODS: Prospectively collected data on patients undergoing pancreatic resection between 1997 and 2009 were reviewed retrospectively. Preoperative and postoperative imaging were analyzed for the presence or absence of venous thrombi. All patients received standard thromboprophylaxis with low-molecular-weight heparin (LMWH). RESULTS: Of 516 pancreatic resections performed, 18 (3.5 %) were complicated by PVST. The most common clinical presentations were abdominal pain (n = 9) and ascites (n = 5) but never any alarm symptoms. Other symptoms were vague and nonspecific (e.g., weight loss, fatigue, fever). Total pancreatectomy was a risk factor compared to hemipancreatectomy (p < 0.01), whereas the underlying disease per se did not make any difference. The median interval between surgery and diagnosis of PVST was 105 days (range 1-1,440 days). PVST was at least a contributing factor in the postoperative deaths of two patients. LMWH therapy did not significantly affect survival. CONCLUSIONS: PVST remains a relatively infrequent complication after pancreatic resection. Because accurate diagnosis and timely intervention may reduce morbidity and mortality, the possibility of PVST should be considered in patients presenting with vague symptoms. Whether anticoagulant treatment is needed is still not clear; there were no obvious differences in outcome between treated and untreated patients.

Survey of the management of acute pancreatitis in surgical departments in Sweden.

OBJECTIVE: Several international guidelines concerning the treatment of acute pancreatitis has been published during the last decades. However, Scandinavian guidelines are still lacking. The aim of the present study is to identify current treatment strategies for acute pancreatitis in Sweden and to evaluate if there is a need for improvement and the role of guidelines. MATERIAL AND METHODS: A questionnaire was e-mailed to the surgical departments at all Swedish hospitals (n = 58) managing patients with acute pancreatitis. Comparisons were made both between university and non-university hospitals, and between hospitals with more versus less than 150,000 persons in the primary catchment population. RESULTS: Fifty-one hospitals responded (88%). In median, 65 (12-200) patients with acute pancreatitis are treated yearly at each hospital. Of 51 hospitals, 18 perform a severity classification, with APACHE II being the most commonly used. A majority are of the opinion that a scoring system is not better than the judgment of a senior consultant. In severe acute pancreatitis, 29/48 routinely administer antibiotics, 29/48 use enteral nutrition, and 25/49 have a standardized follow-up plan. The majority considered administration of intravenous fluids as the most important treatment in severe acute pancreatitis. After mild gallstone-induced acute pancreatitis, the corresponding response was cholecystectomy, especially at larger hospitals (p = 0.002). Of 47, 42 are interested in developing a Scandinavian quality register. CONCLUSIONS: The results from this first Swedish national survey provide an insight into current traditions of treatment of acute pancreatitis and points, for example, at the lack of early severity stratification. A majority of hospitals are interested in developing a quality register in acute pancreatitis.

Reliability of acute pancreatitis diagnosis coding in a National Patient Register: a validation study in Sweden.

AIM: National patient registers are powerful tools in epidemiological research and healthcare administration. As the level of reliability of diagnoses that are partly based on clinical signs, such as acute pancreatitis, may be low, the reliability of discharge diagnoses in these registers needs to be validated. The main aim of this study was to validate the diagnosis coding for acute pancreatitis in the Swedish National Patient Register. METHOD: We randomly sampled 650 admissions of all patients registered in the Swedish National Patient Register with acute pancreatitis or other nonmalignant pancreatic disorders as the main diagnosis in 2007 and 1998, and as the secondary diagnosis in 2007. The medical records for these admissions were reviewed. We analyzed the concordance between the coding of acute pancreatitis in the Swedish National Patient Register and criteria based on internationally accepted diagnostic standards. RESULTS: We received 603 medical records for manual review. Among the 530 patients with a diagnosis of acute pancreatitis in the Swedish National Patient Register, 442 (83%) were, after review, defined as definitive acute pancreatitis, 80 (15%) as probable acute pancreatitis, and 8 (2%) as no acute pancreatitis. There were no significant differences in the reliability of the diagnosis with regard to sex, age, time period or whether the patient had been treated at a county or university hospital. Among the 73 patients registered with a non-malignant pancreatic disorder other than acute pancreatitis, the number of false-negative cases of acute pancreatitis was 23 (32%). They were mainly found among patients registered with a diagnosis of chronic pancreatitis. CONCLUSION: The Swedish National Patient Register is highly reliable as regards correct coding of acute pancreatitis. However, there seems to be a non-negligible share of false-negative cases of acute pancreatitis among patients registered with a diagnosis of chronic pancreatitis.

The variable phenotype of the p.A16V mutation of cationic trypsinogen (PRSS1) in pancreatitis families.

OBJECTIVE: To characterise the phenotypes associated with the p.A16V mutation of PRSS1. DESIGN: Clinical and epidemiological data were collected for any family in which a p.A16V mutation was identified, either referred directly to the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer or via a collaborator. DNA samples were tested for mutations in PRSS1, SPINK1, CFTR and CTRC. PATIENTS: Participants were recruited on the basis of either family history of pancreatitis (acute or chronic) or the results of genetic testing. Families were categorised as having hereditary pancreatitis (HP), idiopathic disease or pancreatitis in a single generation. HP was defined as >or=2 cases in >or=2 generations. Main outcome measures Onset of painful episodes of pancreatitis, death from pancreatic cancer, diagnosis of diabetes mellitus and exocrine pancreatic failure. RESULTS: Ten families with p.A16V mutations were identified (22 affected individuals): six HP families, three with idiopathic disease and one with only a single generation affected. The median age of onset, ignoring non-penetrants, was 10 years (95% CI 5 to 25). There were eight confirmed cases of exocrine failure, four of whom also had diabetes mellitus. There were three pancreatic cancer cases. Two of these were confirmed as p.A16V carriers, only one of whom was affected by pancreatitis. Those with p.A16V pancreatitis were compared to affected individuals with p.R122H, p.N29I and no PRSS1 mutation. No significant differences were proven using logrank or Mann-Whitney U tests. CONCLUSIONS: Penetrance of p.A16V is highly variable and family dependent, suggesting it contributes to multigenic inheritance of a predisposition to pancreatitis.

Survey of the management of pancreatic pseudocysts in Sweden.

OBJECTIVE: The management of pancreatic pseudocysts varies, based mainly on local traditions, resources and expertise. No prospective, randomized study has been done comparing different approaches to treatment. The aim of the present study was to identify current treatment strategies in Sweden. MATERIAL AND METHODS: A questionnaire comprising 12 questions was e-mailed to the surgical departments of all hospitals (n=58) treating patients with pancreatitis. Comparisons were made between university and non-university hospitals and between hospitals with 150,000 or more persons versus less in the primary catchment area. RESULTS: Fifty-one hospitals responded (88%). In median, 4 (0-25) patients were treated yearly due to pancreatic pseudocysts at each hospital. Five hospitals had written guidelines. Multidisciplinary team conferences were held at 36/48 centres. Treatment strategies for acute compared to chronic pancreatitis associated pseudocysts differed significantly depending on the underlying diagnosis in the major hospitals (p=0.005). Overall, 21/49 hospitals refer some of these patients and 15/50 of the departments state that they regularly assist in taking care of patients with pancreatic pseudocysts from other hospitals. The chosen treatment modalities vary widely, above all concerning endoscopic drainage, which is more common for symptomatic non-infected pseudocysts (p=0.005) as well as infected pseudocysts (p=0.004) in university hospitals. CONCLUSIONS: The lack of protocols and management strategies for pancreatic pseudocysts is reflected by the heterogeneity in treatment strategies, as seen in the present survey. Therefore patients may be at risk of receiving suboptimal treatment. A tailored therapeutic approach that takes into consideration patient preferences and involves a multidisciplinary team should be considered in all cases.

[Spinal infection with spinal cord/cauda equina affection requires emergency handling]. / Spinal infektion med ryggmärgs­påverkan kräver snabba åtgärder - Genomgång av Ivo-anmälningar visar att fördröjd handläggning kan ge allvarliga restsymtom.

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.

Non-adhesive organ culture of human biliary epithelium with stroma.

OBJECTIVE: Explanted tissue has been shown to keep adult human cells in organ culture with a preserved morphology for at least one month as spheres in a non-adhesive organ culture. In the present study, we explored whether also human biliary epithelium can be grown in this manner, because the result may be of interest in studies of hepato-biliary-pancreatic carcinogenesis. MATERIAL AND METHODS. Small tissue samples were obtained from the gallbladder wall of patients who had been operated upon with cholecystectomy. Fragments of about 300 microm in diameter from each patient were cultured and investigated with light microscopy at the time of explantation and after 5, 10, 20, 30 and 40 days of culture. Scanning and transmission electron microscopy were performed to demonstrate the ultrastructure. Incubation of cultured fragments with the vital dyes revealed a viable epithelium. RESULTS: At the time of explantation, all the tissue fragments had a rough appearance with an uneven, torn periphery, while during the first few days of culture they became rounder with a smooth-looking surface covering the entire circumference. This spheroid morphology persisted for the remainder of the culture period. The core of the fragments harboured connective tissue with vascular elements, fibroblasts and leucocytes. Immunostaining for cytokeratin 7, 19 and 20 revealed a strong positive staining of the epithelium. CONCLUSIONS: These results show that biliary epithelium can be grown in vitro in a non-adhesive organ culture with their stroma.

Second Giessen International Workshop on Interactions of Exocrine and Endocrine Pancreatic Diseases. Castle of Rauischholzhausen of the Justus-Liebig-university, Giessen (Rauischholzhausen), Germany. March 7-8, 2008.

The 'Second Giessen International Workshop on Interactions of Exocrine and Endocrine Pancreatic Diseases' was organized in order to reflect and discuss recent developments in the field, especially the progress that has been achieved since the first meeting in March 2005. About thirty international specialists were invited to share their experience and thoughts covering the main topics of: A) pancreatic diabetes (type 3c); B) chronic inflammation of the pancreas. The presentations of session A covered an overview about the frequency of exocrine dysfunction in diabetes mellitus, the relation between diabetes, celiac disease and the exocrine pancreas, the prevalence of type 3c diabetes, damage to the pancreas caused by genes, the role of incretins in type 2 and type 3 diabetes, the role of exocrine tissue in beta cell homeostasis, peculiarities in the treatment of type 3c diabetes and a lecture on incretins: from concept to treatment. Session B included presentations about the frequency of chronic inflammation of the pancreas and therapeutical implications, the role of ACE in the pancreas, genomics and the metabolic hypothesis of chronic pancreatitis, nutritional aspects of pancreatic diseases, the stellate cell concept, autoimmunity, genetic background of chronic pancreatitis and the hypothesis of chronic obstruction induced by gallstone disease. The meeting resulted in several new projects that will be started by the participants in the near future.