Surgical techniques for pancreatic cancer.

Surgical resection of pancreatic adenocarcinoma offers the only chance for long-term cure. Over the past 2 decades significant advances have been made in both the surgical techniques and the perioperative care of patients with pancreatic cancer. The operative management of pancreatic cancer involving the head, neck, and uncinate process consists of 2 phases: first, assessing tumor resectability and then, if the tumor is resectable, completing a pancreaticoduodenectomy and restoring gastrointestinal continuity.

Cystic pancreatic neoplasms: observe or operate.

Objective: The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation.

Summary Background Data: With advancements in imaging technology, cystic lesions of the pancreas are being detected with increased frequency. Many of these lesions are small and asymptomatic, but they may be associated with pancreatitis or have malignant potential.

In vitro activities of moxifloxacin against 900 aerobic and anaerobic surgical isolates from patients with intra-abdominal and diabetic foot infections.

The in vitro activities of moxifloxacin, ciprofloxacin, levofloxacin, gatifloxacin, imipenem, piperacillin-tazobactam, clindamycin, and metronidazole against 900 surgical isolates were determined using NCCLS testing methods. Moxifloxacin exhibited good to excellent antimicrobial activity against most aerobic (90.8%) and anaerobic (97.

Cystic pancreatic neoplasms: enucleate or resect?

Asymptomatic cystic pancreatic neoplasms are being detected by abdominal imaging with increasing frequency. Enucleation of small cystic neoplasms can be performed without recurrence but has been associated with a higher incidence of pancreatic fistula. Thus the procedure has been modified to include intraoperative ultrasound imaging and closure of the pancreatic defect.

Diabetes and hyperlipidemia correlate with gallbladder contractility in leptin-related murine obesity.

Obesity is associated with many comorbid conditions including diabetes, hyperlipidemia, and gallstones. However, the interaction among these modalities remains unclear. We recently demonstrated that both leptin-deficient and leptin-resistant obese mice have impaired biliary motility.

Leptin-resistant obese mice have paradoxically low biliary cholesterol saturation.

Background: Human obesity is associated with leptin resistance, elevated serum glucose and lipids, hepatic steatosis, and cholesterol gallstone formation. These gallstones are thought to result from hypersecretion of biliary cholesterol as well as biliary stasis. Leptin-resistant Lep(db) obese mice, which are known to have elevated serum leptin, glucose, and lipids, as well as hepatic steatosis, should be an appropriate model for human gallstone formation.

Gallbladder motility in agouti-yellow and leptin-resistant obese mice.

Background: Obesity is a polygenic disorder that is associated with gallstone disease. We have previously shown that leptin deficiency in obese mice correlates with decreased gallbladder motility, suggesting that leptin plays a role in the link between gallstone disease and obesity. However, most obese humans are leptin-resistant, and relatively few are leptin-deficient.

Improved survival in resected biliary malignancies.

Background: For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor.

Gallstones: genetics versus environment.

Objective: The aim of this study was to determine if a significant genetic component contributes to the pathogenesis of symptomatic gallstones.

Summary Background Data: Gallstones represent a polygenic disorder that affects more than 30,000,000 Americans and results in more than 750,000 cholecystectomies in the United States annually. Risk factors include age, gender, race, parity, obesity, and diabetes.

Decreased gallbladder response in leptin-deficient obese mice.

Obesity is a major risk factor for gallstone formation, but the pathogenesis of this phenomenon remains unclear. Human data on gallbladder emptying are conflicting, and no animal data exist on the effect of obesity on gallbladder motility. Leptin, a hormone produced by adipocytes, is known to have central effects on neuropeptide Y and cholecystokinin, but the influence of leptin on the biliary effects of these hormones is unknown.

Iron deficiency suppresses ileal nitric oxide synthase activity.

Intestinal motility disorders are more common in women of childbearing age who are prone to iron deficiency anemia. The neurotransmitters nitric oxide (NO) and acetylcholine (ACh) play a key role in ileal smooth muscle relaxation and contraction, respectively. Iron-containing heme is known to be a cofactor for nitric oxide synthase (NOS), the enzyme responsible for NO production.

Renal cell carcinoma metastatic to the pancreas: results of surgical management.

Metastatic tumors to the pancreas are uncommon. Renal cell carcinoma is one of the few tumors known to metastasize to the pancreas. The purpose of the current report is to evaluate the surgical management and long-term outcome of patients with metastatic renal cell carcinoma.

Iron deficiency transiently suppresses biliary neuronal nitric oxide synthase.

Background: Iron deficiency results in altered gallbladder and sphincter of Oddi (SO) motility and cholesterol crystal formation. In addition, gallbladder neuronal nitric oxide synthase (nNOS) has been shown to be markedly reduced after 8 weeks on an iron-deficient diet. However, the effects of prolonged iron deficiency on gallbladder and SO nNOS as well as crystal formation have not been determined.

Cholangiocarcinoma.

Despite overall advances in the ability to diagnose and treat patients with cholangiocarcinoma, the prognosis for patients with this malignancy remains poor. Further improvements in the survival of patients with cholangiocarcinoma will come with the early diagnosis of these lesions. New molecular techniques should improve the ability to screen high-risk patients, such as those with primary sclerosing cholangitis, hepatolithiasis, choledochal cysts, and ulcerative colitis.

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

Background: Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined.

Study Design: From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed.

Diagnosis and management of cholangiocarcinoma in primary sclerosing cholangitis.

Cholangiocarcinoma remains difficult to diagnose and is a major cause of death in patients with primary sclerosing cholangitis. Recently serum carcinoembryonic antigen and carbohydrate antigen 19-9 (CA 19-9) levels have been reported to improve diagnostic accuracy in patients with cholangiocarcinoma and primary sclerosing cholangitis. We reviewed our experience with cholangiocarcinoma complicating primary sclerosing cholangitis to identify clinical factors associated with cholangiocarcinoma in patients with primary sclerosing cholangitis and to determine the appropriate management of patients with confirmed or suspected cholangiocarcinoma.

Progesterone alters biliary flow dynamics.

Objective: To test the hypothesis that progesterone alters sphincter of Oddi and gallbladder function and, therefore, bile flow dynamics.

Summary Background Data: Although the effects of progesterone on the biliary tract have been implicated in the increased incidence of gallstones among women, the specific effects of prolonged elevation of progesterone levels, such as occurs with contraceptive progesterone implants and during pregnancy, on the sphincter of Oddi and biliary flow dynamics are still incompletely understood.

Methods: Adult female prairie dogs were randomly assigned to receive subcutaneous implants containing either progesterone or inactive pellet matrix only.

Alterations of the p53 tumor-suppressor gene and K-ras oncogene in perihilar cholangiocarcinomas from a high-incidence area.

We observed a clustering of cholangiocarcinoma in a part of West Virginia. We analyzed the frequency and type of alterations in the p53 tumor-suppressor gene and the K-ras oncogene to determine whether cholangiocarcinomas from this high-incidence area differ from other cholangiocarcinomas at the molecular level. We studied 12 carcinomas of patients from the high-incidence area (West Virginia group), and 15 carcinomas of patients from nearby states (non-West Virginia group).

Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors.

Objective: The objective of this article is to introduce a simple method for classifying cholangiocarcinomas and to apply this system to analyze a large number of patients from a single institution.

Summary Background Data: For the past 2 decades, most western reports on cholangiocarcinoma have separated intrahepatic from extrahepatic tumors and have subclassified this latter group into proximal, middle, and distal subgroups. However, "middle" lesions are uncommon and are managed most often either with hilar resection or with pancreatoduodenectomy.

Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?

Objective: The authors define the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma.

Background: Decreases in perioperative morbidity and mortality and improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma have clearly established a role for this operation when performed with curative intent. However, most surgeons remain hesitant to perform pancreaticoduodenectomy unless surgical margins are widely clear, choosing rather to perform palliative biliary and gastric bypass.

Biliary carcinoembryonic antigen levels are a marker for cholangiocarcinoma.

Background: Cholangiocarcinoma develops in 5% to 15% of patients with choledochal cysts, sclerosing cholangitis, and intrahepatic stones. The detection of cholangiocarcinoma in patients with premalignant biliary conditions has been difficult. Serum levels of carcinoembryonic antigen (CEA) have been neither sensitive nor specific for the diagnosis of cholangiocarcinoma.

The role of preoperative biliary decompression in obstructive jaundice.

Background/aim: This article will examine the current role of preoperative biliary drainage by reviewing risk factors in the jaundiced patient, the results of retrospective and prospective studies of preoperative biliary decompression, and present indications for preoperative biliary drainage.

Materials And Methods: We reviewed 26 articles published between 1934 and 1994.

Results: Information on the following topics is presented: Morbidity and Mortality, Risk Factors, Retrospective Studies, Prospective Randomized Studies, Internal Biliary Drainage, Preoperative Biliary Drainage in the Malnourished Patient, Preoperative Biliary Drainage for Cholangitis, Preoperative Biliary Drainage as a Technical Aid, and Preoperative Biliary Drainage Before Liver Resection.

Perihilar cholangiocarcinoma. Postoperative radiotherapy does not improve survival.

Objective: The aims of this analysis were to determine prospectively the effects of surgical resection and radiation therapy on the length and quality of survival as well as late toxicity in patients with perihilar cholangiocarcinoma.

Background: Retrospective analyses have suggested that adjuvant radiation therapy improves survival in patients with perihilar cholangiocarcinoma. However, in these reports, patients receiving radiotherapy tended to have smaller, often resectable tumors, and were relatively fit.