Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas

PURPOSE

Insulinoma is a rare tumor of the pancreas that can lead to hypoglycemia. To date, the standard therapy is surgical resection. After the first case report of successful endoscopic ultrasound-guided (EUS) ethanol injection 16 years ago, the need for establishing an alternative treatment method remains unchanged given the high morbidity rates of surgery and its unsuitability in some patients.

MATERIALS AND METHODS

Here, we provide retrospective data from 33 insulinoma patients that were treated at our center between 2010 and 2021. Of these, 9 patients were treated with EUS-guided ethanol injection and 24 underwent pancreatic surgery.

RESULTS

The ethanol group was older (ethanol: mean ± SE 67.8±11.2 years vs. surgery: 52.3±15.7, p=0.014) with a higher Charlson Comorbidity Index (3.0 (1.0;4.0) vs. 1.0 (0.0;2.0), p=0.008). The lowest glucose values were similar between groups before (ethanol: 2.09±0.17 mmol/l vs. surgery: 1.81±0.08, p=0.158) and after (4.95±0.74 vs. 5.41±0.28, p=0.581) the respective treatments. Complications occurred more frequently in the surgery group (11 % vs. 54 %, p=0.026). One patient after prior partial pancreatectomy died postoperatively. The hospitalization time was significantly shorter in the ethanol group (4.78±0.78 days vs. 19.88±4.07, p<0.001).

CONCLUSION

EUS-guided ethanol injection can be similarly effective for the treatment of hyperinsulinemic hypoglycemia compared with pancreatic surgery but seems to be associated with less severe complications. This implies the need for prospective randomized trials in insulinoma patients with a low risk for malignancy.

Treatment characteristics and outcomes of pure Acinar cell carcinoma of the pancreas - A multicentric European study on radically resected patients

BACKGROUND

Acinar cell carcinomas (ACC) belong to the exocrine pancreatic malignancies. Due to their rarity, there is no consensus regarding treatment strategies for resectable ACC.

METHODS

This is a retrospective multicentric study of radically resected pure pancreatic ACC. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Further endpoints were oncologic outcomes related to tumor stage and therapeutic protocols.

RESULTS

59 patients (44 men) with a median age of 64 years were included. The median tumor size was 45.0 mm. 61.0% were pT3 (n = 36), nodal positivity rate was 37.3% (n = 22), and synchronous distant metastases were present in 10.1% of the patients (n = 6). 5-Years OS was 60.9% and median DFS 30 months. 24 out of 31 recurred systemically (n = 18 only systemic, n = 6 local and systemic). Regarding TNM-staging, only the N2-stage negatively influenced OS and DFS (p = 0.004, p = 0.001). Adjuvant treatment protocols (performed in 62.7%) did neither improve OS (p = 0.542) nor DFS (p = 0.159). In 9 cases, radical resection was achieved following neoadjuvant therapy.

DISCUSSION

Radical surgery is currently the mainstay for resectable ACC, even for limited metastatic disease. Novel (neo)adjuvant treatment strategies are needed, since current systemic therapies do not result in a clear survival benefit in the perioperative setting.

Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism-New Thresholds for Urgent Perioperative Dialysis

Parathyroidectomy (PTX) is a mainstay of treating secondary hyperparathyroidism (SHPT) in patients with kidney failure in order to reduce the incidence of cardiovascular events (CVE), increase overall survival and improve quality of life. Perioperative hyperkalemia may lead to devastating cardiac complications. Distinct preoperative thresholds for serum potassium levels (SPL) were defined, but neither their usefulness nor consecutive risks are understood. This study compared the results and efficacy of different clinical procedures in preventing or treating perioperative hyperkalemia, including postoperative urgent hemodialysis (UHD). Methods: Patients from Charité-Universitätsmedizin Berlin and Rheinland Klinikum Lukaskrankenhaus, Neuss, undergoing PTX due to SHPT between 2008 and 2018 were analyzed retrospectively with regard to demographic parameters, surgery specific conditions and perioperative laboratory results. Comparisons of patient values from both centers with focus on perioperative hyperkalemia and the need for UHD were performed. Results: A total of 251 patients undergoing PTX for SHPT were included (Neuss: n = 121 (48%); Berlin: n = 130 (52%)). Perioperative hyperkalemia (SPL ≥ 5.5 mmol/L) was noted in 134 patients (53%). UHD on the day of surgery was performed especially in patients with intraoperative hyperkalemia, in females (n = 40 (16%) vs. n = 27 (11%); p = 0.023), in obese patients (n = 27 (40%) vs. n = 50 (28%), p = 0.040) and more often in patients treated in Neuss (n = 42 (35%) vs. 25 (19%); p = 0.006). For patients treated in Neuss, the intraoperative hyperkalemia cut-off level above 5.75 mmol/L was the most predictive factor for UHD (n = 30 (71%) vs. n = 8 (10%); p < 0.001). Concerning secondary effects of hyperkalemia or UHD, no patient died within the postoperative period, and only three patients suffered from acute CVE, with SPL > 5.5 mmol/L measured in only one patient. Conclusion: Perioperative values could not predict postoperative hyperkalemia with the need for UHD. Previously defined cut-off levels for SPL should be reconsidered, especially for patients undergoing PTX. Early postoperative dialysis in patients with postoperative hyperkalemia can be performed with a low risk for complications and may be indicated for all patients with increased perioperative SPL.

Automatized Hepatic Tumor Volume Analysis of Neuroendocrine Liver Metastases by Gd-EOB MRI-A Deep-Learning Model to Support Multidisciplinary Cancer Conference Decision-Making

BACKGROUND

Rapid quantification of liver metastasis for diagnosis and follow-up is an unmet medical need in patients with secondary liver malignancies. We present a 3D-quantification model of neuroendocrine liver metastases (NELM) using gadoxetic-acid (Gd-EOB)-enhanced MRI as a useful tool for multidisciplinary cancer conferences (MCC).

METHODS

Manual 3D-segmentations of NELM and livers (149 patients in 278 Gd-EOB MRI scans) were used to train a neural network (U-Net architecture). Clinical usefulness was evaluated in another 33 patients who were discussed in our MCC and received a Gd-EOB MRI both at baseline and follow-up examination (n = 66) over 12 months. Model measurements (NELM volume; hepatic tumor load (HTL)) with corresponding absolute (ΔabsNELM; ΔabsHTL) and relative changes (ΔrelNELM; ΔrelHTL) between baseline and follow-up were compared to MCC decisions (therapy success/failure).

RESULTS

Internal validation of the model's accuracy showed a high overlap for NELM and livers (Matthew's correlation coefficient (φ): 0.76/0.95, respectively) with higher φ in larger NELM volume (φ = 0.80 vs. 0.71; p = 0.003). External validation confirmed the high accuracy for NELM (φ = 0.86) and livers (φ = 0.96). MCC decisions were significantly differentiated by all response variables (ΔabsNELM; ΔabsHTL; ΔrelNELM; ΔrelHTL) (p < 0.001). ΔrelNELM and ΔrelHTL showed optimal discrimination between therapy success or failure (AUC: 1.000; p < 0.001).

CONCLUSION

The model shows high accuracy in 3D-quantification of NELM and HTL in Gd-EOB-MRI. The model's measurements correlated well with MCC's evaluation of therapeutic response.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]

Hintergrund

Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen.

Methodik

Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen.

Ergebnisse

In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %.

Schlussfolgerung

Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.

Insulinoma in pregnancy (a case presentation and systematic review of the literature)

Insulinomas are rare, benign and functional tumors that coincidentally may become overt during pregnancy or in the post-partum period. As the general symptoms of a pregnancy might cover the clinical presentation, diagnosing remains challenging. We present one additional case of a post-partum insulinoma, combined with a systematic review of the literature to sum up relevant details in diagnosis and treatment. A systematic request of Pubmed/Medline was conducted using the following terms: "insulinoma AND pregnancy" and "insulinoma" for a second request of ClinicalTrials.gov. All publications concerning pregnant or post-partum women with insulinoma were included. Thirty-six cases could be identified for analysis. Each publication was reviewed for demographic, diagnostic and therapeutic data. The most frequent clinical signs were unconsciousness and neurological symptoms. 64.9% were diagnosed during early pregnancy and 35.1% post-partum. 91.9% underwent surgery with a third resected during pregnancy without severe influence on fetal or maternal outcome. Three patients died of metastatic disease or misdiagnosing, two of them miscarried. Insulinoma in pregnancy is rare but should be considered in case of unclear hyperinsulinemic hypoglycemia. Surgery can be performed during the second trimester or post-partum with promising outcome.

How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach

Background. Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. Methods. The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. Results. Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. Conclusions. The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.

[Tips and technical issues for performing transoral endoscopic thyroidectomy with vestibular approach (TOETVA): a novel scarless technique for neck surgery]

BACKGROUND

Nowadays, minimally invasive thyroid and parathyroid gland resections for both benign and malignant tumors are rarely performed. Recently, promising new endoscopic transoral approaches to the anterior neck have been described with good results and few complications. This study describes the first clinical series in Germany using transoral endoscopic thyroidectomy-vestibular approach (TOETVA) and identifies technical issues and solutions.

METHODS

The technique is indicated for hemithyroidectomy in patients without pre-existing neck operations. The technical steps consist of a 10 mm incision at the center of the oral vestibule, followed by subplatysmal hydrodissection. A blunt dissector stick is inserted creating a space below the platysma to the anterior neck and the infrahyoid muscles then three trocars are inserted in the vestibular area. After separation of the infrahyoid muscles, the thyroid isthmus is transected. Anatomical structures, such as the superior thyroid artery, parathyroid glands and the recurrent laryngeal nerve can be easily identified with magnification. Intraoperative neuromonitoring is used routinely, adding safety in avoiding nerve damage.

RESULTS

An optimal operative field due to subplatysmal dissection enables exposure of the thyroid and parathyroid glands. Several critical steps and suitable solutions were identified in the study. 1 Positioning of the team and technical improvements using the a 4K laparoscopic tower allowing enhanced view of the anatomy especially for dissection of the recurrent laryngeal nerve. 2. Lateral and upper positioning of lateral trocars avoiding mental nerve injury. 3. Initial hydrodissection of the subplatysmal space. 4. Use of one dissector progressively creating the operative space in the anterior cervical region. 5. Using internal-external sutures to retract the infrahyoid muscles. 6. Intraoperative neuromonitoring used routinely through the trocars or percutaneously through a 1 mm incision. 7. Extraction of the specimen through a recovery bag. 8. Drainages are possible, but can be avoided in small operative fields.

CONCLUSION

The new TOETVA technique for thyroid surgery is a promising option for selected patients to enable transoral thyroid and parathyroid surgery through the vestibular approach. Further studies in clinical series, especially regarding safety are needed to evaluate the indications of the technique.

Multidetector computed tomography for preoperative assessment of hepatic vasculature and prediction of splenic artery steal syndrome in patients with liver cirrhosis before transplantation

The purpose of this study was to evaluate the accuracy of MDCT for preoperative assessment of hepatic vascular anatomy and the identification of liver-transplantation (OLT) patients at risk of developing subsequent splenic artery steal syndrome (SASS). A total of 145 patients with liver cirrhosis who had undergone OLT and had pre-operative three-phase MDCT (4- to 64-rows) within 100 days before OLT were enrolled retrospectively. MDCT and 3Ds were reviewed by two independent blinded observers (O1/O2). Pre-operative imaging findings were correlated with intra-operative results; findings indicative for SASS were correlated with clinical data and DSA. Among all 145 patients, 16 patients (11%) showed accessory hepatic arteries (accuracy O1/O2, 97%; with 3Ds, 100%); 32 (22%) patients had replaced hepatic arteries (accuracy O1, 97%; O2, 95%; with 3Ds, 100%; kappa = 0.87 and 0.89, P < 0.001). Among 119 patients, 12 patients developed SASS after OLT. The logistic regression model revealed the spleen volume (P = 0.0105) as a predictive factor of SASS. With spleen volumes >or=829 ml, an accuracy of 75% for prediction of SASS was obtained. MDCT with three-dimensional post-processing (3Ds) was highly accurate for pre-operative hepatic vessel evaluation in patients before OLT. In addition, spleen volume was a predictive factor for developing SASS after OLT.

Heterotopic ileal pancreas with lipoma and coexisting fibromatosis associated with a rare case of gastrointestinal bleeding. A case report and review of the literature

CONTEXT

The development of pancreatic tissue outside the confines of the main gland represents a congenital abnormality referred to as heterotopic pancreas. This is a rare pathological and surgical entity which remains mostly asymptomatic.

CASE REPORT

We present the case of a 28-year-old male, who was admitted to hospital because of a history of blood in bowel movements. After a normal gastroscopy and colonoscopy, Tc99m-tagged red blood cells scintigraphy showed enrichment in the right lower abdomen. At double-balloon endoscopy, a intraluminal polypoid mass 8 cm in diameter was revealed 120 cm from the ileocecal valve. The initial macroscopic diagnosis was a gastrointestinal stromal tumor. During surgery, the diagnosis of heterotopic pancreas with lipoma and fibromatosis was made. To our knowledge this is the first case of ileal heterotopic pancreatic tissue and lipoma described to date in the literature.

CONCLUSION

Ileal heterotopic pancreas is a rare entity with potentially life-threatening complications, local excision being the appropriate indicated treatment.

Effect of enteral nutrition and synbiotics on bacterial infection rates after pylorus-preserving pancreatoduodenectomy: a randomized, double-blind trial

OBJECTIVE

Patients undergoing pancreas resection carry several risk factors for nosocomial bacterial infections. Pre- and probiotics (synbiotics) are potentially useful for prevention of these infections.

SUMMARY BACKGROUND DATA

First trials in patients following major abdominal surgery including liver transplantation using one Lactobacillus (LAB) and one fiber showed significant reduction of infection rates and reduced length of antibiotic therapy compared with a control group. The present study was designed to analyze whether a combination of different LAB and fibers would further improve outcome.

METHODS

A prospective randomized monocentric double-blind trial was undertaken in 80 patients following pylorus-preserving pancreatoduodenectomy (PPPD). All patients received enteral nutrition immediately postoperatively. One group (A) received a composition of 4 LAB and 4 fibers, and another group (B) received placebo (fibers only) starting the day before surgery and continuing for 8 days. Thirty-day infection rate, length of hospital stay, duration of antibiotic therapy, noninfectious complications, and side effects were recorded.

RESULTS

The incidence of postoperative bacterial infections was significantly lower with LAB and fibers (12.5%) than with fibers only (40%). In addition, the duration of antibiotic therapy was significantly shorter in the latter group. Fibers and LAB were well tolerated.

CONCLUSION

Early enteral nutrition supplemented with a mixture of LAB and fibers reduces bacterial infection rates and antibiotic therapy following PPPD.

Adult liver transplantation using liver grafts from donors over 70 years of age

The increasing organ shortage calls for widening the selection criteria for liver transplant donors. However, concern exists about the use of grafts from donors older than 70 years. We report our clinical experience with graft-age related outcomes, presenting data on 41 patients transplanted with grafts from older donors.

PATIENTS/METHODS

Between January 1995 and October 2003, 41 liver grafts were transplanted from donors older than 70 years. We analyzed patient and graft survival, incidence of retransplantation, initial nonfunction (INF), rejection, intra- and postoperative requirement for red blood cells. We also recorded cholestasis, protein synthesis and urinary retention.

RESULTS

The mean donor age was 73.4 +/- 0.37 years. After one year, the patient survival was 91% and the graft survival 86%. The retransplantation rate was 9.75%; only one graft was lost due to INF. We observed an incidence of 11 rejection episodes. Of these, five patients needed OKT3 therapy for steroid-resistent rejection. The intra- and postoperative requirement for red blood cells was 4.0 +/- 0.65 and 1.4 +/- 0.25 units. Cholestasis, protein synthesis, and urinary retention parameters were within normal limits.

CONCLUSIONS

Among donors of mean age 73.4 years, patient and graft survivals were excellent. One organ was lost due to INF. The intra- and postoperative need for red blood cells was within acceptable ranges. Liver function tests, cholestasis, and retention parameters were normal after 1 year follow up. Thus, we recommend to accept liver grafts from donors older than 70 years to expand the organ pool.

Older liver graft transplantation, cholestasis and synthetic graft function

Older liver grafts are often discarded because of conservative selection criteria. We report on our clinical experience with graft-age related outcome. Patients transplanted with livers older than 70 years (70.2-80.2 years, n = 38) were compared with controls transplanted with livers younger than 70 years. Pairs were matched for age, gender, indication and cold ischemic time. Mean donor age was 73.4 +/- 2 vs. 39 +/- 16 years. Patient and graft survival did not differ between both groups after 1-year follow-up (P = 0.19 and P = 0.24 respectively). Retransplantation rate was 10.5% vs. 5.3% (P = 0.40). Initial poor function occurred in two patients in the study group versus four patients in the control group (P = 0.69). The incidence of rejection episodes was comparable. Parameters of cholestasis and protein synthesis showed no difference 1-year post-transplant. Mean age of donor organs in matched pairs group B was near by half of that in the older donor group A (39.0 vs. 73.4 years). Post-transplant outcome as indicated by patient and graft survival was comparable between both groups. Donor organ age had no impact on postoperative organ function. We recommend to accept liver grafts from organ donors older than 70 years to expand the donor pool.