Pancreatic head resection for chronic pancreatitis in patients with extrahepatic generalized portal hypertension.

BACKGROUND: Five percent to 10% of chronic pancreatitis (CP) cases are complicated by portal venous occlusion leading to extrahepatic generalized portal hypertension (GPH). Pancreatic head resections (PHR) are regarded risky or contraindicated in patients with extrahepatic GPH. The aim of our study was to analyze the outcome of patients with extrahepatic GPH undergoing PHR for CP and to propose recommendations for surgical strategy. METHODS: Sixteen of 185 patients with PHR suffered from extrahepatic GPH. Perioperative and follow-up data were documented prospectively and analyzed to assess the outcome. RESULTS: Preoperative interventional thrombolysis of the portal vein was successfully performed in 5 patients and alleviated further PHR. Median operative time and blood transfusions were higher in patients with extrahepatic GPH compared with patients without extrahepatic GPH (P<.01). Overall complication rate was not statistically different (44% vs 34%). One death occurred in each group. At the end of follow-up (median, 18 months) 13 of 15 patients with extrahepatic GPH were free of pain. No variceal bleeding or cholestasis was documented. All patients judged their status as subjectively improved. CONCLUSION: Although technically demanding in the presence of extrahepatic GPH, PHR can be performed with an acceptable morbidity and mortality in an experienced center. Preoperative interventional recanalization of portal vein thrombosis may render PHR possible by restoring normal splanchnic blood flow in selected cases indicated for surgery.

Encapsulated cells expressing a chemotherapeutic activating enzyme allow the targeting of subtoxic chemotherapy and are safe and efficacious: data from two clinical trials in pancreatic cancer.

Despite progress in the treatment of pancreatic cancer, there is still a need for improved therapies. In this manuscript, we report clinical experience with a new therapy for the treatment of pancreatic cancer involving the implantation of encapsulated cells over-expressing a cytochrome P450 enzyme followed by subsequent low-dose ifosfamide administrations as a means to target activated ifosfamide to the tumor. The safety and efficacy of the angiographic instillation of encapsulated allogeneic cells overexpressing cytochrome P450 in combination with low-dose systemic ifosfamide administration has now been evaluated in 27 patients in total. These patients were successfully treated in four centers by three different interventional radiologists, arguing strongly that the treatment can be successfully used in different centers. The safety of the intra-arterial delivery of the capsules and the lack of evidence that the patients developed an inflammatory or immune response to the encapsulated cells or encapsulation material was shown in all 27 patients. The ifosfamide dose of 1 g/m2/day used in the first trial was well tolerated by all patients. In contrast, the ifosfamide dose of 2 g/m2/day used in the second trial was poorly tolerated in most patients. Since the median survival in the first trial was 40 weeks and only 33 weeks in the second trial, this strongly suggests that there is no survival benefit to increasing the dose of ifosfamide, and indeed, a lower dose is beneficial for quality of life and the lack of side effects. This is supported by the one-year survival rate in the first trial being 38%, whilst that in the second trial was only 23%. However, taking the data from both trials together, a total of nine of the 27 patients were alive after one year, and two of these nine patients were alive for two years or more.

Celiac axis stenosis in pancreatic head resection for chronic pancreatitis.

BACKGROUND AND AIMS: To determine the outcome of pancreatic head resection for chronic pancreatitis in the presence of celiac axis stenosis or occlusion we analyzed the blood supply of the upper abdominal organs in 11 patients before and after surgery. PATIENTS AND METHODS: Between March 1994 and April 2000 we performed 145 pancreatic head resections for chronic pancreatitis. Preoperatively 11 patients showed celiac axis stenosis at angiography. All 11 patients underwent duplex ultrasonography postoperatively and 8 had magnetic resonance angiography during follow-up. RESULTS: In two cases division of the median arcuate ligament was performed to reestablish hepatic artery blood flow. No further revascularization procedures of the celiac axis were necessary. Postoperative duplex ultrasonography and magnetic resonance angiography showed normal blood flow in five patients. Four patients still had an occlusion or a significant celiac axis stenosis, and two had a stenosis only during expiration. At follow-up nine patients were completely free of abdominal pain (82%), and all had gained weight postoperatively, ranging from 5 to 16 kg. CONCLUSIONS: Our data suggest that celiac axis stenosis infrequently causes complications in pancreatic head resection for chronic pancreatitis and therefore does not represent a contraindication for this procedure. Nevertheless the hepatopedal blood flow must be confirmed by palpation or duplex ultrasonography after pancreatic head resection in these patients.