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Objectives: Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. ‍This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries., Materials and Methods: A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients., Results: Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively., Conclusion: Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.

Objective: Previous studies have identified a significant volume-outcome relationship for hospitals performing pancreaticoduodenectomy (PD). However, scant information exists concerning the effects of increased caseload of PD within the same hospital. Here, we describe the effects of becoming a high-volume provider of PD., Material and Methods: The study group comprised 221 patients who underwent PD between 2000 and 2012. Hospital volume was allocated into three groups: low-volume (<10 PDs/year), years 2000-2004, n = 25; medium-volume (10-24 PDs/year), years 2005-2009, n = 86; and high-volume (≥25 PDs/year), years 2010-2012, n = 110., Results: The annual number of PDs increased from 5 in 2000 to 39 in 2012. The median operative duration decreased over the volume categories (p < 0.001). Intraoperative blood loss dropped (p < 0.001). The need for intraoperative blood transfusion was reduced (p < 0.001). Increasing hospital volume was associated with fewer reoperations (p = 0.041) and shorter postoperative length of stay (p = 0.010). There was a tendency toward reduced mortality: 4.0% for the low-volume period, 2.3% for the medium-volume period, and 0% for the high-volume period (p = 0.066)., Conclusions: The transition from a low- to a high-volume center resulted in optimized outcomes for PD and 0% operative mortality, favoring the continued centralization of this high-risk operation.

OBJECTIVE. Severity of acute pancreatitis (AP) can vary from a mild to a fulminant disease with high morbidity and mortality. Cost analysis has, however, hitherto been sparse. The aim of this study was to calculate the cost of acute pancreatitis, both including hospital costs and costs due to loss of production. MATERIAL AND METHODS. All adult patients treated at Skane University Hospital, Lund, during 2009-2010, were included. A severity grading was conducted and cost analysis was performed on an individual basis. RESULTS. Two hundred and fifty-two patients with altogether 307 admissions were identified. Mean age was 60 ± 19 years, and 121 patients (48%) were men. Severe AP (SAP) was diagnosed in 38 patients (12%). Thirteen patients (5%) died. Acute biliary pancreatitis was more costly than alcohol induced AP (p < 0.001). Total costs for treating mild AP (MAP) in patients ≤65 years old was lower (p = 0.001) and costs for SAP was higher (p = 0.024), as compared to older patients. The overall hospital cost and cost for loss of production was per person in mean €5,100 ± 2,400 for MAP and €28,200 ± 38,100 for SAP (p < 0.001). The costs for treating AP during the two-year-long study period were in mean €9,762 ± 19,778 per patient. Extrapolated to a national perspective, the annual financial burden for AP in Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants. CONCLUSIONS. The costs of treating AP are high, especially in severe cases with a long ICU stay. These results highlight the need to optimize care and continue the identification and focus on SAP, in order to try to limit organ failure and infectious complications.

Management of colorectal liver metastases (CRLM) has dramatically changed during the last decade and has now become more multimodal and aggressive, including the use of downstaging chemotherapy, portal vein embolization to increase the function of the liver remnant or both in combination. Radiofrequency ablation is also an option in CRLM, potentially combined with surgical resection. Results are quite convincing concerning the safety of liver resection also when performed following neoadjuvant chemotherapy. Sparing liver parenchyma in patients with bilobar liver metastatic disease subjected to liver resection may be possible without endangering surgical radicality. Sparing liver parenchyma when using neoadjuvant chemotherapy, a chemotherapy-free period of 6 weeks or more seems to positively affect liver regeneration. There is still the possibility to reresect recurrent liver lesions, though there seems to be a tendency toward fewer reresections following the use of adjuvant chemotherapy.

Objective: Compare perioperative course and long-term mortality after liver resection for colorectal cancer (CRC) metastases between patients who had preoperative treatment with portal vein embolization (PVE) and chemotherapy or chemotherapy alone., Methods: Among patients undergoing liver resection for CRC metastases following preoperative chemotherapy treatment, 17 patients who had received preoperative PVE (group A) were compared with 17 matched controls who had no PVE (group B). Perioperative course and long-term mortality were compared between groups A and B and between group A and the entire group of 75 cases with preoperative chemotherapy (group C)., Results: Baseline characteristics for the matched groups A and B were similar. Group C included less major resections. Median intraoperative bleeding was 1600 ml in group A, 1200 ml in group B, and 1000 ml in group C (p < 0.05 vs. group A). Median postoperative stay was comparable in all groups (8-9 days). Operation time was 542 min in group A and 464 min in group B (p < 0.01). Mortality after 30 days and 1, 2, and 5 years was similar in all groups., Conclusion: Perioperative outcome and long-term survival did not differ when comparing liver resection for CRC liver metastases preceded by PVE and chemotherapy or chemotherapy alone, except for the operation time. The study supports the safety of this "aggressive" combination approach in patients in need of tumor "downstaging" by chemotherapy and PVE to increase the remnant liver volume.

Objective: Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare clinical entity. The objective of this study was to review a single institution's experience with this uncommon tumor, as well as review the literature., Material and Methods: Consecutive patients, who underwent surgery for a pathologically confirmed SPN between 1991 and 2010, were retrospectively reviewed. A PubMed search (January 1980-June 2011) was conducted to identify risk factors for death among SPN patients., Results: The institutional review identified 16 patients with SPN. Thirteen patients were female and three patients were male (median age 34 years). All patients underwent radical resection. Two patients had metastatic disease at the time of operation as evident by the presence of lymph node metastasis and gallbladder metastasis. One developed liver metastasis 4 months postoperatively and subsequently died. The other patient received adjuvant chemotherapy (gemcitabine and capecitabine), and 23 months after the initial operation, no tumor recurrence was detected and the patient is still alive. All other patients remain disease-free. Analysis of 29 fatalities reported in the English literature (including the present case) revealed several atypical features including male gender, old age, tumor size >5 cm, diffuse growth pattern, cellular or nuclear atypia, high mitotic rate, extensive necrosis, extrapancreatic invasion, metastasis and incomplete resection., Conclusions: SPN is not always indolent. Male patients and those with old age, atypical histopathology (large tumors, diffuse growth, cellular/nuclear atypia, mitotic activity, necrosis, invasion/metastasis) and incomplete resection may have a higher risk of recurrence and death, deserving particular attention.

Chronic pancreatitis is a relatively frequent condition usually caused by alcoholic abuse but also due to recurrent gallstone disease, metabolic endocrine disorders and haemochromatosis, among others. Specific types such as hereditary and autoimmune pancreatitis should be particularly kept in mind and emphasized, as they require specific treatment and attention. The possibility to identify gene mutations has also increased and this is likely to decrease the overall total number of "idiopathic" chronic pancreatitis cases. Pancreatic stellate cells have been identified as potential key players in the progression of chronic pancreatitis and the development of fibrogenesis, which are activated either during repeated attacks of necro-inflammation or directly by toxic factors. The inhibition or modulation of pancreatic stellate cells could represent a way of potential intervention in patients with chronic pancreatitis in the future.

Objective: Patients with chronic pancreatitis and intractable pain may be candidates for surgical intervention and various types of surgery have been described over time. The objective of this study was to describe long-term outcome following pancreaticojejunostomy in patients with chronic pancreatitis., Material and Methods: Thirty-two patients with chronic pancreatitis underwent lateral pancreatiocojejunostomy and were then followed-up for 5 years., Results: The short-term results on relief of abdominal pain were good, but seemed to deteriorate at long-term follow-up (5 years), as did pancreatic exocrine and endocrine function. A substantial number of patients admitted to continued alcohol abuse at 5-year follow-up (31%)., Conclusions: Pancreaticojejunostomy in patients with chronic pancreatitis renders good pain relief. In effect, the deterioration in abdominal pain at long-term follow-up was in parallel with a tendency towards a decline in both exocrine and endocrine function and a continued alcohol abuse.

Objective: Pancreatic ductal adenocarcinoma is a highly lethal disease and most patients are not eligible for curable resection. Estimation of prognosis is essential in order to provide the best individual treatment for patients with pancreatic adenocarcinoma. Prediction of survival by current methods is limited, therefore the objective of this study was to determine possible prognostic factors identified at the time of diagnosis., Material and Methods: All 119 consecutive patients with pancreatic ductal adenocarcinoma receiving palliative treatment at the Department of Surgery, Lund University Hospital from 1999 through 2002 were reviewed retrospectively. Prognostic factors and interventions were analysed statistically. C-reactive protein (CRP) at the time of diagnosis was measured in 109 patients., Results: The overall median survival was 4.4 months. By means of a multivariate analysis it was shown that CRP (p<0.001) and tumour size (p=0.018) were independent predictors of survival. The median survival of patients with normal CRP at the time of diagnosis was 10.8 months versus 4.2 months for those with raised CRP levels (>or=5 mg/l; p<0.001). Chemotherapy was the only intervention associated with a longer survival time (p<0.001 versus no chemotherapy)., Conclusions: The poor prognosis for patients with pancreatic ductal adenocarcinoma was confirmed. CRP proved to be a strong independent predictor of survival. Together with previous reported factors, CRP could serve as a potential tool to determine future treatment strategies for optimal individual palliation.

Objective: Peritoneal adhesions develop after almost all surgical interventions in the abdomen. We have developed an efficient treatment against post-surgical adhesions consisting of a combination of positively charged poly-L-lysine and negatively charged poly-L-glutamate. The aim of the present study was to further develop the concept of applying oppositely charged polypeptides in the prevention of adhesion formation, by evaluating different doses of the peptides, alterations in the way of administration, and also testing alternative components., Material and Methods: Eighty-five NMRI mice were divided into six groups. A standardized peritoneal injury model was used. The groups received physiologic sodium chlorine, poly-L-lysine+poly-L-glutamate, low molecular weight poly-L-lysine+poly-L-glutamate, locally administered poly-L-lysine+poly-L-glutamate, in vitro mixed poly-L-lysine+poly-L-glutamate and poly-L-arginine+poly-L-glutamate, respectively. After 7 days, the extent of adhesion formation was determined during relaparotomy and was expressed as the mean percentage of the total wound length., Results: A significant decrease (p <0.001) in the peritoneal adhesion rate was detected in all groups, with the exception of the group administered poly-L-arginine. Among those animals that received poly-L-lysine and poly-L-glutamate, the low dose of poly-L-lysine administration resulted in the most pronounced anti-adhesive effect., Conclusions: The most effective polypeptide combination was poly-L-lysine and poly-L-glutamate, also showing effectiveness when used at low doses and by local application. The differences in adhesion prevention and the possible underlying mechanisms are discussed and the key role of poly-L-lysine is elucidated.

Objective: To evaluate a novel antiadhesive polypeptide complex containing a combination of poly-L-glutamate and poly-L-lysine in order to study its effectiveness and mechanisms in the prevention of postoperative abdominal adhesions in mice., Material and Methods: The length of peritoneal adhesions was measured and expressed in percentage of the wound length in a standardized peritoneal injury model and evaluated 7 days and 4 weeks after adhesion induction. The test compound was administered intraperitoneally following surgery. Peritoneal swabs, including the wound area, were stained in order to determine the peritoneal location and clearance of the polypeptides. Electron microscopy was performed to analyze the wound surface and the ultra-structural changes of the phagocytes in cell culture. Moreover, flow cytometry was used to evaluate the effect on macrophage phagocytic function., Results: The poly-L-lysine and poly-L-glutamate combination significantly decreased peritoneal adhesions both at 7 days' (p < 0.001) and 4 weeks' (p < or = 0.001) follow-up. From the first day, the compound was found in the wound, after which this was gradually rebuilt, and covered with mesothelial cells. The macrophages phagocytosed the test compound particles, resulting in significant cell growth, and large phagocytic vacuoles., Conclusions: The intraperitoneal administration of poly-L-lysine and poly-L-glutamate resulted in a significant decrease in experimental postoperative peritoneal adhesions.

Objective: Intraperitoneal adhesions are an important cause of postoperative intestinal obstruction, abdominal discomfort and infertility. In the present study we hypothesized that a combination of polypeptides with different surface properties, resulting in fine disperse low-soluble complexes, could be of benefit in the prevention of abdominal adhesions., Material and Methods: Various polypeptides including lysozyme, polyglutamate, polylysine and combinations of all three were evaluated as compared to hyaluronic acid. A standard wound on the parietal peritoneum in mice was used and the evaluated agents were administered immediately postoperatively. The extent of peritoneal adhesions to the injured area was measured and expressed as a percentage of the wound length as evaluated after 7 days. Flow cytometry was performed to evaluate the effect on peritoneal macrophage survival and phagocytic function and the Pick test was used to determine peroxide production in order to estimate toxicity and potential impairment of macrophage function caused by the chemicals., Results: Significant differences were seen among the treatment groups (p<0.001). Both polyglutamate and lysozyme, and polyglutamate together with polylysine significantly decreased adhesion formation as compared to hyaluronic acid. The polylysine-polyglutamate combination was still visible macroscopically on the peritoneal surface after 1 week, though not after 1 month. The polyglutamate-lysozyme mixture was less effective than these individual components alone. The chemicals did not show any toxic effects or altered function in macrophage cell culture., Conclusions: Lysozyme, polyglutamate and, most effectively, a polyglutamate-polylysine combination significantly decreased experimental abdominal adhesion formation. A strong mechanical connection to the wound and prolonged attendance in the surface were noted. Peritoneal phagocyte function did not seem to be influenced by the chemicals.