PANCREATIC SURGERY

Endogenous vasoactive mediators such as bradykinin and nitric oxide ma y affect the severity and outcome of acute pancreatitis by altering th e capillary integrity of the pancreatic microcirculation. Protease inh ibitors such as gabexate have a small beneficial effect on pancreatiti s-related morbidity but are not cost effective. Secondary pancreatic i nfection after necrotizing pancreatitis can be mitigated by selective gut decontamination but requires both oral and intravenous antibiotic administration. Combined modality treatment of pancreatic duct stones is safe and effective but may not have better or even equivalent long- term efficacy as compared with traditional surgery. Duodenum-preservin g resections (Beger and Frey procedures) are especially useful in pati ents with chronic pancreatitis who have predominant involvement of the pancreatic head, and such procedures have fewer metabolic and nutriti onal consequences as compared with standard pancreatoduodenectomy. Isl et autotransplantation combined with pancreatic resection for patients with small-duct disease not amenable to surgical duct decompression i s safe and provides effective long-term pain relief. Cyst fluid analys is in patients with problematic pancreatic cysts may help to different iate neoplastic cysts from pseudocysts, especially when other diagnost ic studies yield inconsistent results. Mucin-hypersecreting tumors of the pancreas comprise a recently identified group of tumors with varie d histopathology and malignant potential. Resection is generally recom mended. Combined modality staging in patients with pancreatic cancer i s strongly recommended to identify patients most likely to benefit fro m attempted surgical resection. Pylorus-sparing resection results in l ess impairment of digestive function than conventional pancreatoduoden ectomy with no difference in survival. More effective adjuvant or neoa djuvant therapies are needed to extend the long-term survival benefits of surgery in patients with potentially resectable disease.