Spiral computed tomography for preoperative staging of potentially resectable carcinoma of the pancreatic head

BACKGROUND: Pancreatic cancer is often locally invasive. Preoperative staging attempts to identify patients suitable for resection, in order to minimize unnecessary operations. The aim of this study was to assess the improved imaging provided by spiral computed tomography (CT) in the preoperative staging of potentially resectable pancreatic head carcinoma. METHODS: In 56 consecutive patients with pancreatic head carcinoma spiral CT findings were correlated prospectively with operative and histopathological findings. Criteria for irresectability at CT were infiltration of the peripancreatic fat and vascular ingrowth grade D, on a scale from A to F. RESULTS: At operation 27 (48 per cent) of 56 tumours were irresectable. Small metastases were found in seven patients (12 per cent). Ingrowth (adherence) to the portal or mesenteric vein was present in 19 patients (34 per cent). The sensitivity and specificity of CT for irresectability were 78 and 76 per cent respectively. Resection rates with a vascular margin free of tumour were 100 per cent for grade A, 63 per cent for grade B, 44 per cent for grade C, 15 per cent for grade D and 0 per cent for grade E, with a predictive value for ingrowth of 88 per cent for grades D or higher. The resectability rate was 11 per cent (one of nine) when infiltration of the anterior peripancreatic fat was present and 67 per cent when infiltration was absent (P <0.01). CONCLUSION: Spiral CT with thin slices seems to improve detection of distant metastases and vascular ingrowth in patients with pancreatic head carcinom

Endotoxin, cytokines, and endotoxin binding proteins in obstructive jaundice and after preoperative biliary drainage

BACKGROUND—Obstructive jaundice is associated with postoperative complications related to increased endotoxaemia and the inflammatory response. In animals obstructive jaundice is associated with endotoxaemia and cytokine induction, which are reversed by internal biliary drainage.
AIMS—To study endotoxaemia and the subsequent inflammatory response in obstructive jaundiced patients and after endoscopic biliary drainage.
METHODS—In 15 patients with malignant distal obstructive jaundice, inflammatory and bacteriological parameters were assessed before endoscopic stent placement and after three weeks endoscopic drainage.
RESULTS—Drainage reduced bilirubin from 252.5 to 45.1 µmol/l. At baseline low level endotoxaemia was detected (4.3 pg/ml) which was not affected after drainage (4.5 pg/ml). Serum interleukin 8 (IL-8) and endotoxin binding proteins were increased in jaundice and reduced after drainage (IL-8 113.6 to 20.7 pg/ml; lipopolysaccharide binding protein 24.2 to 16.5 µg/ml; sCD14 17.4 to 7.6 µg/ml; bactericidal/permeability increasing protein 2.9 to 1.8 ng/ml). Levels of other cytokines, augmented in animals, were only slightly increased and not changed after drainage (tumour necrosis factor (TNF): 21.7 and 18.4 pg/ml; sTNFr p55/75: 2.9/7.0 and 2.7/5.6 ng/ml; IL-6: 4.2 and 6.1 pg/ml; IL-10: 4.5 and 2.7 pg/ml). Elastase and lactoferrin tended towards reduction after drainage. All bile cultures were positive after stenting.
CONCLUSIONS—The effects of obstructive jaundice in humans on endotoxin and cytokines are different from those in animal models. Obstructive jaundice causes alterations in circulating endotoxin binding proteins and IL-8. Concentrations of other mediators (TNF, previously suggested as being responsible for systemic endotoxaemia effects) are low and not affected by drainage.


Keywords: endotoxin; obstructive jaundice; cytokines; endotoxin binding protein

Pre- en postoperatieve bestraling bij de behandeling van de resectabele Klatskin-tumor

Proximal bile duct carcinoma (Klatskin tumour) is infrequent and difficult to treat. In principle, surgery is indicated. The usefulness of irradiation after resection is controversial in the literature. This article describes the experiences gained in the Academic Medical Centre of Amsterdam with pre- and postoperative irradiation of resectable Klatskin tumours. Preoperative irradiation (10.5 Gy) is administered to devitalize detached tumour cells in the bile, to prevent implantation metastases after resection. Postoperative irradiation has been administered since 1986 according to protocol. An analysis of 71 patients, of whom 48 had been irradiated after resection while 23 had not, showed a statistically significant prolongation of survival in the group irradiated postoperatively. Radiotherapy was administered externally (55 Gy) or in combination with internal radiotherapy (45 Gy external, 10 Gy internal). For internal irradiation, the source of radiation (Iridium-192) was introduced along the bile duct anastomoses via the soma formed by the blind end of the Roux-Y jejunal loop used for bile duct reconstruction. Since internal irradiation in combination with external irradiation caused more complications, while there was no difference of survival from patients only irradiated externally, the complete postoperative irradiation is currently being given from the outside. Pre- and postoperative irradiation may contribute to the success of the treatment of the resectable Klatskin tumou

Validation of the Rockall risk scoring system in upper gastrointestinal bleeding

BACKGROUND—Several scoring systems have been developed to predict the risk of rebleeding or death in patients with upper gastrointestinal bleeding (UGIB). These risk scoring systems have not been validated in a new patient population outside the clinical context of the original study. 
AIMS—To assess internal and external validity of a simple risk scoring system recently developed by Rockall and coworkers. 
METHODS—Calibration and discrimination were assessed as measures of validity of the scoring system. Internal validity was assessed using an independent, but similar patient sample studied by Rockall and coworkers, after developing the scoring system (Rockall's validation sample). External validity was assessed using patients admitted to several hospitals in Amsterdam (Vreeburg's validation sample). Calibration was evaluated by a χ(2) goodness of fit test, and discrimination was evaluated by calculating the area under the receiver operating characteristic (ROC) curve. 
RESULTS—Calibration indicated a poor fit in both validation samples for the prediction of rebleeding (p<0.0001, Vreeburg; p=0.007, Rockall), but a better fit for the prediction of mortality in both validation samples (p=0.2, Vreeburg; p=0.3, Rockall). The areas under the ROC curves were rather low in both validation samples for the prediction of rebleeding (0.61, Vreeburg; 0.70,Rockall), but higher for the prediction of mortality (0.73, Vreeburg; 0.81,Rockall). 
CONCLUSIONS—The risk scoring system developed by Rockall and coworkers is a clinically useful scoring system for stratifying patients with acute UGIB into high and low risk categories for mortality. For the prediction of rebleeding, however, the performance of this scoring system was unsatisfactory. 

 Keywords: upper gastrointestinal bleeding; risk scoring; prognostic factors; rebleeding; mortalit