1
|
Faucher P, Beuvon F, Fignani D, Sebastiani G, Afonso G, Zhou Z, Dousset B, Boitard C, Dotta F, Mallone R, Larger E. Immunoregulated insulitis and slow-progressing type 1 diabetes after duodenopancreatectomy. Diabetologia 2021; 64:2731-2740. [PMID: 34522983 DOI: 10.1007/s00125-021-05563-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
AIMS/HYPOTHESIS We report the case of a woman who underwent a partial pancreatectomy for a serous cystadenoma when aged 56 years. She had been diagnosed with diabetes 6 years before and had Hashimoto's thyroiditis. Despite positive anti-GAD autoantibodies (GADA) and previous surgery, she was transiently weaned off long-acting insulin. Blood glucose levels remained well controlled with low-dose long-acting insulin. Insulin needs eventually increased 8 years after surgery, in conjunction with anti-zinc transporter 8 (ZnT8) seroconversion and decreasing residual C-peptide. We hypothesised that the surgical pancreas specimens and blood autoimmune T cell responses may provide correlates of this indolent clinical course. METHODS Beta and alpha cell area and insulitis were quantified on pancreas head tissue sections obtained at surgery. Blood T cell responses against beta cell antigens were analysed by enzyme-linked immunospot. RESULTS Pancreas sections displayed reduced beta cell and normal alpha cell area (0.27% and 0.85% of section area, respectively). High-grade insulitis was observed, mostly in insulin-containing islets, with a peri-insulitis pattern enriched in T cells positive for regulatory forkhead box protein 3 (FOXP3). In vitro challenge with beta cell antigens of circulating T cells collected 4 and 9 years after surgery revealed dominant and persistent IL-10 responses; IFN-γ responses increasing at 9 years, after anti-ZnT8 seroconversion, was observed. CONCLUSIONS/INTERPRETATION Despite persistent GADA and the histopathological finding of insulitis and decreased beta cell area 6 years after diabetes diagnosis, glycaemic control was maintained with low-dose insulin up to 8 years after surgery. Regulated T cell responses towards beta cell antigens and FOXP3-positive peri-insulitis suggest spontaneous long-term regulation of islet autoimmunity after substantial beta cell loss, and eventual autoimmune progression upon anti-ZnT8 seroconversion.
Collapse
Affiliation(s)
- Pauline Faucher
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France
- Service de Diabétologie et Immunologie Clinique, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France
| | - Frédéric Beuvon
- Service d'Anatomie Pathologique Publique, Cochin Hospital, Assistance Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France
| | - Daniela Fignani
- Department of Medicine, Surgery and Neurosciences, Diabetes Unit, University of Siena, Siena, Italy
- Fondazione Umberto Di Mario, c/o Toscana Life Sciences, Siena, Italy
| | - Guido Sebastiani
- Department of Medicine, Surgery and Neurosciences, Diabetes Unit, University of Siena, Siena, Italy
- Fondazione Umberto Di Mario, c/o Toscana Life Sciences, Siena, Italy
| | - Georgia Afonso
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France
| | - Zhicheng Zhou
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France
| | - Bertrand Dousset
- Service de Chirurgie Digestive Publique, Cochin Hospital, Assistance Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France
| | - Christian Boitard
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France
- Service de Diabétologie et Immunologie Clinique, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France
| | - Francesco Dotta
- Department of Medicine, Surgery and Neurosciences, Diabetes Unit, University of Siena, Siena, Italy
- Fondazione Umberto Di Mario, c/o Toscana Life Sciences, Siena, Italy
| | - Roberto Mallone
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France
- Service de Diabétologie et Immunologie Clinique, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France
| | - Etienne Larger
- Institut Cochin, CNRS, Inserm, Université de Paris, Paris, France.
- Service de Diabétologie et Immunologie Clinique, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université de Paris, Paris, France.
| |
Collapse
|
2
|
Pitombo MB, Goumard C, Lim C, Sancio JB, Mazzola A, Prat F, Vaillant JC, Conti F, Perdigao F. Vena Cava and Pancreatic head En Bloc Resection for an Invasive Inferior Vena Cava Leiomyosarcoma in a Liver Transplant Patient. Clin Res Hepatol Gastroenterol 2021; 45:101609. [PMID: 33662783 DOI: 10.1016/j.clinre.2020.101609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND De novo neoplasms are one of the major causes of death in patients after the first year of liver transplantation. The occurrence of sarcomas is extremely rare and the survival is often poor. However, early diagnosis and radical surgical treatment, may benefit some select liver transplant patients. METHOD We describe the case of a liver transplant patient who developed a locally advanced inferior vena cava (IVC) leiomyosarcoma, who underwent radical surgical treatment with resection of the IVC associated with duodenopancreatectomy, right nephrectomy, and IVC reconstruction. We address aspects of the diagnosis and surgical strategy. CONCLUSION This case report illustrates that IVC and multivisceral resections may be feasible and safe in highly selected liver transplant recipients. Major surgery should not be excluded as treatment option in an immunosuppressed liver transplant patient.
Collapse
|
3
|
Papagni V, Piacente C, Varvara M, Vincenti L. Unexpected duodenopancreatectomy in an "awake" gastrectomized patient: Case report and technical notes. Int J Surg Case Rep 2021; 81:105781. [PMID: 33773372 PMCID: PMC8024909 DOI: 10.1016/j.ijscr.2021.105781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 11/25/2022] Open
Abstract
A patient with a previous history of gastric cancer was admitted to our unit with fever and jaundice. Preoperative evaluation showed the presence of calculi of the common bile duct (CBD). During the preoperative anaesthetic evaluation, neuraxial-type anaesthesia was proposed given the patient’s frailty. Exploration of the CBD revealed neoplastic tissue involving the ampulla of Vater. A duodenopancreatectomy was performed under neuraxial anaesthesia. A modified reconstruction was performed, and a mechanical stapler for hepaticojejunal (HJ) anastomosis was used. The outpatient follow-up showed physical recovery of the patient with a resumption of appetite and weight gain, and HJ anastomosis showed no stricture during the MRI performed 5 months after the operation.
Introduction and importance Early diagnosis, surgical techniques and adjuvant therapy in patients undergoing gastrectomy for cancer have prompted an increase in the number of long-term surviving patients. The detection of pancreatic head tumours in patients undergoing gastrectomy is challenging, even for expert surgeons. Case presentation A 78-year-old woman presented with a previous history of gastric cancer treated 2 years before D2 total gastrectomy and Roux-an-Y reconstruction. The patient reported uneven tissue located on the head of the pancreas 6 months after the operation. MRI showed dilation of the intrahepatic bile ducts and common bile duct stones. During the preoperative evaluation, neuraxial-type anaesthesia was proposed to the patient given her frailty. After choledochotomy, solid tissue involving the ampulla of Vater was found. Although not originally planned, a duodenopancreatectomy (DP) was performed under neuraxial anaesthesia. Clinical discussion The approach to DP in patients with a history of gastrectomy and Roux-en-Y reconstruction requires a modified surgical approach, which is not standardized. Other cases of DP performed on patients under neuraxial anaesthesia are not described in the literature. Performing a modified reconstruction, we can reduce the number of intestinal anastomoses and the risk of anastomotic dehiscence. The choice of neuraxial anaesthesia has been demonstrated to be a suitable solution for the patient with rapid recovery. Conclusion In our experience, DP is a safe and feasible procedure in gastrectomized patients. Mechanical hepaticojejunal (HJ) anastomosis is a possible alternative to traditional manual anastomosis. Neuraxial anaesthesia in selected patients can be considered a safe practice for rapid postoperative recovery compared to general anaesthesia.
Collapse
Affiliation(s)
- V Papagni
- Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy; General Surgery "Balestrazzi" Policlinico of Bari, Bari, Italy.
| | - C Piacente
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University, Bari, Italy
| | - M Varvara
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University, Bari, Italy
| | - L Vincenti
- General Surgery "Balestrazzi" Policlinico of Bari, Bari, Italy
| |
Collapse
|
4
|
Salinas W, Marani M, Reimondez S, Alcaraz Á, Signorini F, Maraschio M, Giordano E, Obeide L. Solid pseudopapilar neoplasm of the pancreas. CIR CIR 2021; 89:263-268. [PMID: 33784288 DOI: 10.24875/ciru.19001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Solid pseudopapillary tumor of the pancreas is a rare entity, more frequent in women between the 2nd and 4th decades. The diagnosis is usually incidental and it can be reached by computed tomography or magnetic resonance imaging. Subsequent pathological confirmation is necessary for an adequate treatment. A retrospective study of six cases was carried out. All the patients were female, between 14 and 56 years of age, in which 50% the tumor were an incidental finding. We had three cases located in the head and three in the body of the pancreas. We performed three pancreaticoduodenectomies and three distal pancreatectomies with splenic preservation, without disease recurrence.
Collapse
Affiliation(s)
- Walter Salinas
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Marcos Marani
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Santiago Reimondez
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Álvaro Alcaraz
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Franco Signorini
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Martin Maraschio
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Enzo Giordano
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Lucio Obeide
- General Surgery Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| |
Collapse
|
5
|
Pedrazzoli S, Brazzale AR. Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management. Langenbecks Arch Surg 2020; 405:1219-31. [PMID: 33104886 DOI: 10.1007/s00423-020-02005-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/29/2020] [Indexed: 01/04/2023]
Abstract
Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management. Electronic supplementary material The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.
Collapse
|
6
|
Tringali A, Valerii G, Boškoski I, Familiari P, Landi R, Perri V, Costamagna G. Endoscopic snare papillectomy for adenoma of the ampulla of vater: Long-term results in 135 consecutive patients. Dig Liver Dis 2020; 52:1033-8. [PMID: 32532606 DOI: 10.1016/j.dld.2020.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/17/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The premalignant nature of ampullary adenomas justifies their radical excision. AIMS Aim of this study is to evaluate the long-term results of endoscopic snare papillectomy in a consecutive series of patients with ampullary adenomas. METHODS Patients who underwent endoscopic snare papillectomy between October 1999 and October 2017 were identified from an electronic database. Endoscopic snare papillectomy was performed en bloc, when possible; a pancreatic stent or a nasopancreatic drainage were inserted. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly. RESULTS Endoscopic snare papillectomy was performed in 135 patients (70 M, mean age 60.5 years) by en bloc (83%) or piecemeal (17%) resection. Delayed bleeding occurred in 16 patients (11.8%), infected retroperitoneal collections in 6 patients (4.4%), pancreatitis in 4 patients (3%). One patient died (0.7%). Follow-up was available in 103/114 (90.3%) patients. In case of residual (24.3%) and recurrent (23.3%), adenomas endoscopic retreatment was successful in 42/49 cases (85.7%). After a mean follow-up of 40 months, 93.2% (96/103) of the patients were disease free CONCLUSION: Endoscopic snare papillectomy of ampullary adenomas is effective with favorable long-term outcomes. Compliance to the scheduled follow-up is important for the early detection and re-treatment of recurrences.
Collapse
|
7
|
Shekarriz J, Keck T, Shekarriz H. Computerized Medical Evidence-Based Decision Assistance System "MEBDAS®" improves in-hospital outcome after pancreatoduodenectomy for pancreatic cancer. Pancreatology 2020; 20:746-750. [PMID: 32312611 DOI: 10.1016/j.pan.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 02/02/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Indication for pancreatoduodenectomy for pancreatic cancer can be challenging. Wrong decisions in indication processes lead to significant health impairments. Computerized decision support systems can take over parts of decision-making processes, making them more accurate. MEBDAS® is a decision-supporting software that predicts outcomes of proposed treatments. AIM to determine the decision concordance between MEBDAS® and multidisciplinary tumour board (MTB) and the impact of MEBDAS® on in-hospital outcome at different indication thresholds. METHODS 126 patients with pancreatoduodenectomy from a high-volume university hospital were included. Outcome indicators were in-hospital mortality, Comprehensive Complication Index (CCI®), therapy-related loss of "Quality-Adjusted-Life-Day" (QALD-loss) and prognostic gain of treatment-related "Quality-Adjusted-Life-Year" (QALY-gain). RESULTS The concordance of decisions was 94.4% at the indication threshold of 0. By raising the indication threshold to 1 year, the concordance decreased to 0%, the in-hospital-mortality dropped from 2.52% to 0%, the CCI® decreased from 26.47 to 13.90, the therapy-related QALD-loss declined from 21.53 to 16.22 days and the prognostic QALY-gain increased from 0.374 to 0.906 years. At IT = 0.250 years, the concordance was 61.11% and differences between MTB and MEBDAS®-group were highly significant (p < 0.001) for all outcome parameters: mortality (3.97% vs. 1.30%), CCI® (28.96 vs. 18.29), therapy-related QALD-loss (24.41 vs. 15.19 days) and QALY-gain (0.351 vs. 0.501 years). CONCLUSION MEBDAS® decisions are superior to those of MTB in terms of in-hospital-outcome. The inclusion of MEBDAS® in decision procedure makes the indication more accurate and reduces morbidity and mortality. In addition, MEBDAS® can increase patients' competence by involving them in decision-making process.
Collapse
Affiliation(s)
- J Shekarriz
- Department of Surgery, University Hospital Schleswig-Holstein Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
| | - T Keck
- Department of Surgery, University Hospital Schleswig-Holstein Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - H Shekarriz
- University of Luebeck, Ratzeburger Allee 160, 23568, Luebeck, Germany
| |
Collapse
|
8
|
Lardinois MJ, Meurisse N. Pancreas-sparing and superior mesenteric artery first approach in duodenal adenocarcinoma of the fourth portion of duodenum: A case report. Int J Surg Case Rep 2018; 45:13-16. [PMID: 29558711 PMCID: PMC6000720 DOI: 10.1016/j.ijscr.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/02/2018] [Indexed: 01/13/2023] Open
Abstract
Adenocarcinoma of the distal duodenum is uncommon with bad prognosis. Pancreas-sparing resection is preferred to avoid pancreatectomy-related morbi-mortality. The artery-first approach of the SMA should be considered by surgeons to early identify contra-indications to proceed during operation. The aim of surgery is R0 resection with 5-year survival between 25% and 75%.
Introduction Peroperative assessment of resectability in pancreas-sparing duodenectomy for distal duodenal (D3-D4) adenocarcinoma is challenging for surgeons. Presentation of case We report a 68-year-old man with biopsy-proven adenocarcinoma of the fourth portion of duodenum which had been diagnosed with upper endoscopy and CT. A pancreas-sparing duodenectomy with loco-regional lymph node resection using the superior mesenteric artery first approach was performed. Discussion Adenocarcinoma of the fourth portion of duodenum is rare. It has non-specific symptoms. The diagnosis is difficult and is frequently delayed. Surgery is the only chance of cure. After peroperative assessment of resectability, with intraoperative ultrasound, complete exposition of the duodenum and entire dissection of the superior mesenteric artery (SMA) using the artery-first approach technique should be done to assess for tumor resectability, which should include the possibility of complete lymphadenectomy of the mesenteric root. If technically feasible, a pancreas-sparing resection should be preferred to avoid pancreatectomy-related morbi-mortality. The aim of the surgery is a R0 resection which has a 5-year survival rate between 25% and 75%. Conclusion Artery-first approach of the SMA should be considered by surgeons in adenocarcinoma of the distal duodenum to identify any contra-indications to proceed further.
Collapse
Affiliation(s)
| | - Nicolas Meurisse
- Abdominal and Transplant Surgery department, University of Liège, Belgium
| |
Collapse
|
9
|
Bäcker H, Beeres FJ, Rossi M, Scheiwiller A. Gastric perforation after duodenopancreatectomy. Med Mycol Case Rep 2017; 18:21-23. [PMID: 28794960 PMCID: PMC5536876 DOI: 10.1016/j.mmcr.2017.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/18/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022] Open
Abstract
Fungal and bacterial infections are often which may cause sepsis. Mucormycosis is an unfrequent, but often life-threatening disease. A timely diagnosis and treatment is the cornerstone of success. An increase in incidence can be expected, given an aging population and increasing incidence of obesity, diabetes and cancer. We present a rare case where early diagnosis has helped to treat the patient mainly with antifungal therapy as surgical therapy has had high risk of complications.
Collapse
Affiliation(s)
- Henrik Bäcker
- Luzerner Kantonsspital, Spitalstrasse CH-6000 Lucerne 6, Switzerland
| | - Frank Jp Beeres
- Luzerner Kantonsspital, Spitalstrasse CH-6000 Lucerne 6, Switzerland
| | - Marco Rossi
- Luzerner Kantonsspital, Spitalstrasse CH-6000 Lucerne 6, Switzerland
| | | |
Collapse
|
10
|
Alfieri S, Quero G, Rosa F, Di Miceli D, Tortorelli AP, Doglietto GB. Indications and results of pancreatic stump duct occlusion after duodenopancreatectomy. Updates Surg 2016; 68:287-293. [PMID: 27631168 DOI: 10.1007/s13304-016-0384-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/15/2016] [Indexed: 12/19/2022]
Abstract
Severe post-operative complications after pancreaticoduodenectomy (PD) are largely due to pancreatic fistula onset. The occlusion of the main pancreatic duct using synthetic glue may prevent these complications. Aim of this study is to describe this technique and to report short- and long-term results as well as the post-operative endocrine and exocrine insufficiency. Two hundred and four patients who underwent PD with occlusion of the main pancreatic duct in a period of 15 years were retrospectively analyzed. Post-operative complications and their management were the main aim of the study with particular focus on pancreatic fistula incidence and its treatment. At 1-year follow-up endocrine and exocrine functions were analyzed. We observed a 54 % pancreatic fistula incidence, most of which (77/204 patients) were a grade A fistula with little change in medical management. Twenty-eight patients developed a grade B fistula while only 2 % of patients (5/204) developed a grade C fistula. Nine patients required re-operation, 5 of whom had a post-operative grade C fistula. Post-operative mortality was 3.4 %. At 1-year follow-up, 31 % of patients developed a post-operative diabetes while exocrine insufficiency was encountered in 88 % of patients. The occlusion of the main pancreatic duct after PD can be considered a relatively safe and easy-to-perform procedure. It should be reserved to selected patients, especially in case of soft pancreatic texture and small pancreatic duct and in elderly patients with comorbidities, in whom pancreatic fistula-related complications could be life threatening.
Collapse
Affiliation(s)
- Sergio Alfieri
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy
| | - Giuseppe Quero
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy
| | - Fausto Rosa
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy
| | - Dario Di Miceli
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy
| | - Antonio Pio Tortorelli
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy
| | - Giovanni Battista Doglietto
- Divisione di Chirurgia Digestiva, Fondazione Policlinico "A. Gemelli", Istituto di Clinica Chirurgica, Rome, Italy.
| |
Collapse
|
11
|
Quesada R, Andaluz A, Cáceres M, Moll X, Iglesias M, Dorcaratto D, Poves I, Berjano E, Grande L, Burdío F. Long-term evolution of acinar-to-ductal metaplasia and β-cell mass after radiofrequency-assisted transection of the pancreas in a controlled large animal model. Pancreatology 2015; 16:38-43. [PMID: 26639388 DOI: 10.1016/j.pan.2015.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic duct ligation (PDL) has been used as a model of chronic pancreatitis and as a model to increase β-cell mass. However, studies in mice have demonstrated acinar regeneration after PDL, questioning the long-term validity of the model. We aim to elucidate whether RF-assisted transection (RFAT) of the main pancreatic duct is a reliable PDL model, both in short (ST, 1-month) and long-term (LT, 6-months) follow-ups. METHODS Eleven pigs were subjected to RFAT. Biochemical (serum/peripancreatic amylase and glucose) and histological changes (including a semiautomatic morphometric study of over 1000 images/pancreas and IHC analysis) were evaluated after ST or LT follow-up and also in fresh pancreas specimens that were used as controls for 1 (n = 4) and 6 months (n = 6). RESULTS The distal pancreas in the ST was characterized by areas of acinar-to-ductal metaplasia (56%) which were significantly reduced at LT (21%) by fibrotic replacement and adipose tissue. The endocrine mass showed a normal increase. CONCLUSION RFAT in the pig seems to be an appropriate PDL model without restoration of pancreatic drainage or reduction of endocrine mass.
Collapse
Affiliation(s)
- Rita Quesada
- Cancer Research Group HBP, Fundación Instituto Mar de Investigaciones Médicas, Doctor Aiguader 88, Barcelona 08003, Spain.
| | - Anna Andaluz
- Medicine and Surgery of Animals Department, Facultat de Veterinària, Universitat Autònoma de Barcelona, Bellaterra, Barcelona 08193, Spain
| | - Marta Cáceres
- General and Digestive Surgery Department, Hospital Universitari Sagrat Cor, Viladomat 288, 08029 Barcelona, Spain
| | - Xavier Moll
- Medicine and Surgery of Animals Department, Facultat de Veterinària, Universitat Autònoma de Barcelona, Bellaterra, Barcelona 08193, Spain
| | - Mar Iglesias
- Department of Pathology, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain
| | - Dimitri Dorcaratto
- Hepatobiliary and Liver Transplant Surgical Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ignasi Poves
- General Surgery Department, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain
| | - Enrique Berjano
- Biomedical Synergy, Electronic Engineering Department, Universitat Politècnica de València, Valencia 46022, Spain
| | - Luis Grande
- General Surgery Department, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain
| | - Fernando Burdío
- General Surgery Department, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain
| |
Collapse
|
12
|
Guglielmo N, Montalto GM, Della Pietra F, Garofalo M, Mennini G, Melandro F, Berloco PB. Spontaneous Bilateral Adrenal Haemorrhage after Duodenopancreatectomy: a case report. Clin Ter 2015; 166:e111-3. [PMID: 25945442 DOI: 10.7417/ct.2015.1831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
it is difficult to diagnose because of its nonspecific presentation. This condition frequently occurs in association with an extreme physical stress and may lead to acute adrenal insufficiency or death if not promptly and properly treated. We report a rare case of acute bilateral adrenal hemorrhage with adrenal insufficiency following duodenopancreatectomy for ampulloma in absence of surgical complications. Early diagnosis and corticosteroid replacement with aggressive management of the precipitating pathology are essential to enable a successful outcome.
Collapse
Affiliation(s)
- N Guglielmo
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - G M Montalto
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - F Della Pietra
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - M Garofalo
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - G Mennini
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - F Melandro
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| | - P B Berloco
- Department "Paride Stefanini", General Surgery and Organ Transplant, Sapienza University of Rome, Italy
| |
Collapse
|
13
|
Nigri G, Petrucciani N, La Torre M, Magistri P, Valabrega S, Aurello P, Ramacciato G. Duodenopancreatectomy: open or minimally invasive approach? Surgeon 2014; 12:227-34. [PMID: 24525404 DOI: 10.1016/j.surge.2014.01.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 01/11/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures. METHODS A systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model. RESULTS For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD. CONCLUSIONS The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.
Collapse
Affiliation(s)
- Giuseppe Nigri
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy.
| | - Niccolò Petrucciani
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| | - Marco La Torre
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| | - Paolo Magistri
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| | - Stefano Valabrega
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| | - Paolo Aurello
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| | - Giovanni Ramacciato
- Department of Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
| |
Collapse
|
14
|
Tonelli F, Giudici F, Nesi G, Batignani G, Brandi ML. Biliary tree gastrinomas in multiple endocrine neoplasia type 1 syndrome. World J Gastroenterol 2013; 19:8312-8320. [PMID: 24363522 PMCID: PMC3857454 DOI: 10.3748/wjg.v19.i45.8312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/29/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe our patients affected with ectopic biliary tree gastrinoma and review the literature on this topic.
METHODS: Between January 1992 and June 2012, 28 patients affected by duodenopancreatic endocrine tumors in multiple endocrine neoplasia type 1 (MEN1) syndrome underwent surgery at our institution. This retrospective review article analyzes our experience regarding seventeen of these patients subjected to duodenopancreatic surgery for Zollinger-Ellison syndrome (ZES). Surgical treatment consisted of duodenopancreatectomy (DP) or total pancreatectomy (TP). Regional lymphadenectomy was always performed. Any hepatic tumoral lesions found were removed during surgery. In MEN1 patients, removal of duodenal lesions can sometimes lead to persistence or recurrence of hypergastrinemia. One possible explanation for this unfavorable outcome could be unrecognized ectopic localization of gastrin-secreting tumors. This study described three cases among the seventeen patients who were found to have an ectopic gastrinoma located in the biliary tree.
RESULTS: Seventeen MEN1 patients affected with ZES were analyzed. The mean age was 40 years. Fifteen patients underwent DP and two TP. On histopathological examination, duodeno pancreatic endocrine tumors were found in all 17 patients. Eighty-one gastrinomas were detected in the first three portions of the duodenum. Only one gastrinoma was found in the pancreas. The mean number of gastrinomas per patient was 5 (range 1-16). Malignancy was established in 12 patients (70.5%) after lymph node, liver and omental metastases were found. Three patients exhibited biliary tree gastrinomas as well as duodenal gastrinoma(s). In two cases, the ectopic gastrinoma was removed at the same time as pancreatic surgery, while in the third case, the biliary tree gastrinoma was resected one year after DP because of recurrence of ZES.
CONCLUSION: These findings suggest the importance of checking for the presence of ectopic gastrinomas in the biliary tree in MEN1 patients undergoing ZES surgery.
Collapse
|
15
|
Chara L, Rodríguez B, Holgado E, Ramírez N, Fernández-Rañada I, Mohedano N, Arcediano A, García I, Cassinello J. An unusual metastatic renal cell carcinoma with maintained complete response to sunitinib treatment. Case Rep Oncol 2011; 4:583-6. [PMID: 22220154 PMCID: PMC3251249 DOI: 10.1159/000335016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Recently, metastatic renal cell carcinoma (mRCC) treatment has changed dramatically with the onset of new therapies against molecular targets replacing immunotherapy as standard treatment. We report the case of a 49-year-old patient with a moderately differentiated renal clear cell carcinoma without extracapsular extension who underwent radical nephrectomy. Eight months after surgery, he developed a thyroid metastasis which was also treated surgically with a hemithyroidectomy. Seventy-five months after nephrectomy, the patient presented an upper gastrointestinal bleeding due to a duodenal metastasis that infiltrates the head of the pancreas. The treatment applied was surgery by duodenopancreatectomy, with positive surgical margins in the pathologic study. In addition to this, the extension study showed lung metastases requiring initiation of systemic treatment with sunitinib. The patient presented an excellent response to treatment, showing complete clinical and radiological response at 5 months of treatment (RECIST criteria) and a disease-free survival of 48 months until now, without evidence of toxicity. RCC has the potential to metastasize to almost any location, but thyroid and duodenal metastases in RCC are extremely rare. Moreover, this case also highlights the good responses that can be achieved in terms of disease-free survival, low toxicity and quality of life in this new era of therapies against molecular targets.
Collapse
Affiliation(s)
- Luis Chara
- Medical Oncology Service, Guadalajara University General Hospital, Guadalajara, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
Annular pancreas (AP) is a rare congenital anomaly. Coexisting malignancy has been reported only in a few cases. We report what is, to the best of our knowledge, the first case in the English literature of duodenal adenocarcinoma in a patient with AP. In a 55-year old woman with duodenal outlet stenosis magnetic resonance cholangiopancreatography showed an aberrant pancreatic duct encircling the duodenum. Duodenojejunostomy was performed. Eight weeks later she presented with painless jaundice. Duodenopancreatectomy revealed a duodenal adenocarcinoma, surrounded by an incomplete AP. Thus, co-existent malignancy with AP can be present without obstructive jaundice and without being visible through preoperative diagnostics.
Collapse
|