Early and late results from 298 patients with chronic pancreatitis who were surgically treated by means of duodenum-preserving pancreatic head resection (DPPHR) were prospectively analyzed. The aim of this operative procedure is to treat complications of chronic pancreatitis caused by inflammatory enlargement of the pancreatic head by decompressing the common bile duct, the pancreatic duct, the duodenum, and the retropancreatic intestinal vessels. End points of the study were early and late postoperative outcome. The follow-up period ranged from 1 to 22 years with a median follow-up of 6 years. In-hospital mortality was 1%, postoperative morbidity was 28.5%, and the rate of repeat laparotomy was 5.7%. Diabetes mellitus developed early in the postoperative period in six patients (2%). After a median follow-up of 6 years, late mortality was 8.9%. In the late follow-up period 88% of our patients were completely free of pain or had infrequent episodes and 63% were able to return to work. DPPHR might be considered as an alternative surgical technique in the treatment of chronic pancreatitis if the dominant lesion is in the pancreatic head.

In 205 patients with necrotizing pancreatitis, surgery was carried out following failure of medical treatment. Intraoperatively, according to the size of the necrotic area and the weight of the surgically removed necrotic tissue, 79 patients showed a limited panereatic necrosis, and 126 patients an extended necrotizing process. In 40.4% of 138 patients with bacteriological reports, a bacterial contamination of the pancreatic necrosis was found. The main objective of surgical management was the removal of the necrotic tissue. This was performed with 2-way drainage and postoperative continuous peritoneal and/or local lavage, in a smaller group of patients with inner drainage of the necrosis cavity, and in a few patients with drainage alone. The overall hospital mortality rate was 24.4%. The Iowest mortality was achieved in patients treated with necrosectomy and postoperative continuous local lavage (6.0%). In patients with necrosis of approximately 30% of the pancreas, mortality was lower (7.6%) than in patients with a 50% necrosis (24.0%) or in patients with a subtotal/total necrosis (51.0%) (p < 0.0001). Formation of extrapancreatic necrosis resulted in a significantly increased mortality rate (p < 0.02). In patients with bacterially contaminated necrosis, a mortality rate of 32.1% was found, whereas in patients with a steri|e neerosis, mortality was down to 9.8% (p < 0.01). Based on the results of this study, we eonclude that the clinical course of necrotizing pancreatitis depends essentially on the extent of the necrosis in the pancreas itself, the development of extrapancreatic necrosis, and the bacteriological status of the necrotic area. Adequate surgical management leads to a considerably increased survival rate of patients with necrotizing pancreatitis.

The diagnostic place value of CA 19-9, a tumor-associated antigen, was tested in 611 patients. This group of patients included 273 patients who suffered from a malignant disease (48 patients with pancreatic carcinomas and 225 patients with extrapancreatic malignant growths) and 338 patients with benign diseases (66 patients with chronic pancreatitis, 36 patients with acute pancreatitis, and 236 patients with general surgical diseases). In 93% of the patients with pancreatic carcinoma (media value, 528 U/ml), in 37% and 19% of the patients with carcinoma of the stomach and colorectal carcinomas (median value 8 U/ml), respectively, the CA 19-9 value was estimated as being above the normal limits of 6 to 37 U/ml. A sensitivity of 93% and a specificity of 85%, as well as a total accuracy of 82%, were established in pancreatic carcinoma during preoperative observation. The preoperatively raised CA 19-9 concentration in patients with pancreatic carcinomas dropped after curative resection of the carcinoma to within normal limits. However, a serum concentration of less than 37 U/ml was not recorded in any CA 19-9 estimation after a palliative surgical intervention, or in any case of inoperable carcinomas.

The present case report demonstrates the history of a 50-year-old man with a mixed endocrine-neurogenous tumor of the ampulla of Vater. The tumor was localized endo-scopically after an attack of melena. There were no signs of endocrinopathy. A local resection with suturing of the pancreatic duct was performed. Morphologically, there were two different tissue types (neurogenous and carcinoid-like) with numerous cells and nerve fibers reacting immunohistochemically with somatostatin and neurotensin antisera: some immunoreactivity to PP-antibodies was observed. Still, after 20 months, the patient seems to have been cured by local resection.