Cephalic Duodenopancreatectomy Research Articles

Routes and types of microbial infection in the pathology of pancreatic adenocarcinoma

Introduction/Objective. Pancreatic cancer may be accompanied by infections caused by various microorganisms. It is uncertain wheatear pancreatic infection precedes the development of cancer or vice versa. The aim of this study is to analyze routes of infections from the duodenum through the pancreatic duct to determine what types of microorganisms can get through this duct into the pancreas and nearby tissue. Methods. In patients subjected to cephalic duodenopancreatectomy (Whipple procedure) due to adenocarcinoma of the ampulla of Vater, the duodenum or head of the pancreas, swabs from duodenal mucosa, pancreatic duct, and pancreatic tissue at the line of the resection were taken. Microscopic slides were prepared directly from the patients? specimens as well as from colonies on culture plates, and both were Gram stained. Results. Candida was present in all three types of swabs (duodenum, pancreatic duct, and tissue), while bacteria, depending on the species (Pseudomonas aeruginosa, ?-hemolytic Streptococcus, coagulasenegative Staphylococcus, Enterococcus spp., Serratia spp.), were present in pancreatic duct or tissue, but not in the duodenum. Conclusion. There is a connection between the presence of microorganisms and pathology of the pancreatic adenocarcinoma. Results show that Candida infection originates from the duodenum, while bacterial infections originate directly from blood or tissue injuries.

Implementación de un centro de referencia regional en cirugía pancreática. Experiencia tras 631 procedimientos

IntroductionThe main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. MethodDescriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. Results631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02). ConclusionsThe experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.

Anastomosis ducto-mucosa reforzada (REDMA). Nueva alternativa tras la duodenopancreatectomía cefálica

IntroductionOf the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]). MethodsRetrospective observational study, between January 2017 and March 2020, of patients undergoing CPD in our unit after applying the inclusion and exclusion criteria. Analysis of preoperative, intraoperative factors and postoperative complications observed during follow-up. ResultsSample of 34 patients; 67.6% (n = 23) of them under the classic protocol and 32.4% (n = 11) with REDMA. The only post-surgical complication in which we obtained statistical repercussion, without differences between cases and controls in terms of the risk of FPP, in favor of the REDMA anastomosis is that of FPP. Thanks to this surgical innovation, both the complications from stage IIIb, according to the Clavien-Dindo classification, and the mean hospital stay have also been reduced with statistical significance. ConclusionsWhen REDMA reduces the rate of PPF in patients with moderate/high surgical risk of it, we consider it to be a useful alternative to consider in the reconstruction of transit after CPD.

Quality of life analysis after Whipple procedure. Retrospective cohort study

Introduction: Patient reported outcomes establish the patient’s own perception about his/her health and enable the development of policies designed to improve health/disease processes. These are particularly helpful in the case of diseases with a significant impact on the patient’s quality of life.
 Objective: To compare the quality of life scores assessed using the EQ-5D-5L questionnaire in patients undergoing cephalic duodenopancreatectomy (Whipple procedure) and laparoscopic cholecystectomies in the same hospital.
 Methodology: Retrospective cohort trial between July 2018 and February 2020. Patients programmed for cephalic duodenopancreatectomy were included, regardless of the type of pathology, and over 18 years old. Patients with carcinomatosis or vascular infiltration were excluded. The EQ-5D-5L was administered following Whipple surgery and compared against a control group (laparoscopic cholecystectomy). The demographic characteristics, the diagnosis, hospital stay and 60-day mortality were assessed.
 Results: A total of 68 patients were included. The most frequent diagnosis was pancreatic cancer (30 %) in the Whipple group and lithiasis (100 %) in the control group. In the five dimensions assessed, there were no differences in terms of mobility (OR: 0.41, 95 % CI [0.30-0.57], p = 0.103) and in terms of personal care (OR: 0.42, 95 % CI [0.32-0.58], p = 0.254). There was a difference in daily life activities (OR: 0.38, 95 % CI [0.27-0.54], p = 0.017), pain/malaise (OR: 2.33, 95 % CI [0.99-5.48]), p = 0.013 and anxiety/depression (OR: 0.39, 95 % CI [0.28-0.55], p = 0.019). The overall health perception was 80 points for Whipple (IQR 60-90) vs. 100 points for the control group (IQR 90-100).
 Conclusions: Patients undergoing a Whipple procedure experience a health perception slightly lower than patients undergoing laparoscopic cholecystectomy. This difference may be associated with increased pain, anxiety/depression and a reduction in their activities of daily life. The administration of the EQ-5D-5L questionnaire to measure quality of life is a friendly tool that used be used routinely to plan activities aimed at improving medical care.

Metástasis duodenal de cáncer de mama. Presentación atípica y resolución quirúrgica no habitual

Breast cancer is the most frequent malignant tumor and the leading cause of death worldwide. The most frequent sites of metastatic involvement are the bone, liver and lung, and less than 1% compromise the gastrointestinal tract. The case of a patient with a history of breast cancer treated with chemotherapy and subsequent duodenal relapse is presented below. A cephalic duodenopancreatectomy (CDP) and adjuvant chemotherapy were performed with favorable evolution.

Pancreatic fistula: A major complication of cephalic duodenopancreatectomy that should be known

We report the case of a 41-year-old female patient without a cardiovascular risk factor, who underwent a cephalic duodenopancreatectomy (CDP) for a gastrointestinal stromal tumor of the duodenum invading the pancreas. On postoperative day 5, the patient presented a hemorrhagic shock requiring hemostatic laparotomy with the placement of 2 Delbet blades. On day 8, she again presented a hemorrhagic shock requiring arterial embolization. On day 11 of the CDP, the patient presented a septic shock with fever at 39 °C, chills, multiple organ failure: respiratory (dyspnea with polypnea at 30 cycles/min), and cardiac (tachycardia at 120 beats/min) requiring oxygen therapy with a high concentration mask and the use of vasoactive amine. The patient also exhibited a digestive fluid leaking through the Delbet blades. Biologically, procalcitonin was 0.97 ng/mL and C-reactive protein (CRP) increased from 285.41 to 318.97 mg/L. Analysis of the fluid leaking through the Delbet blades found an amylase level of 326 IU/L (approximately 7× the normal value). Hemoglobin was 10 g/dL, prothrombin time (PT) was 70%, and a platelet count was 250 000 mm3. The diagnosis of septic shock on pancreatic fistula was suggested and an abdominopelvic computed tomography (CT) was requested. The latter made it possible to highlight at the level of the surgical site on the anterior aspect of the pancreatic-jejunal anastomosis a collection containing an air bubble, thus, confirming the presence of a pancreatic fistula (Figure 1). The patient underwent an emergency CT-guided percutaneous drainage (Figure 2) associated with a triple antibiotherapy. The outcome was overall uneventful, with clinical and biological improvement, with a CRP two days after the percutaneous drainage at 221.80 mg/L. The CT scan performed 2 weeks after the drainage, found a complete drying of the collection, with however, a focal infection of the abdominal wall (Figure 3).

Preservation of an intra-pancreatic hepatic artery during a duodenopancreatectomy

Background: Detailed knowledge of the anatomic variations of the hepatic artery is essential when operating on pancreatic tumours. We present a case report and possible consequences of one of the anatomical variations where the right hepatic artery arises from the superior mesenteric artery (SMA) and travels not behind, but through the head of the pancreas. This is a rarely observed abnormality and there is lack of published literature. Material & Methods: A 62 y-o gentleman presented to our emergency department with jaundice, no abdominal pain. A USS and MRI scan was performed and they showed marked dilatation of the main pancreatic duct and the intra and extra hepatic biliary duct by ampuloma. A left suprarenal mass of 45 x 42mm was also identified. A Cephalic duodenopancreatectomy and left adrenalectomy was performed. During the procedure a left hepatic artery branch of the left gastric artery was found and an aberrant right hepatic artery was identified, it was originated in the SMA and then showed a trajectory through the pancreatic parenchyma. This aberrant artery was easily dissected along its intra-pancreatic path and was successfully preserved. The patient showed an uneventful recovery. Discussion: Only a few cases of an intra-pancreatic hepatic artery with origin in the SMA have been reported . In almost all cases, the aberrant artery was preserved because its intra-pancreatic dissection was found to be favourable. There was an avascular dissection plane surrounding the artery as it traversed the pancreas. Preserving the artery is the preferred option, whereas if injured, the reconstruction is believed to be safe, in this case a simple revascularisation is impossible due to the absence of a gastro-duodenal artery therefore, the recommended published options are: splenic artery transposition and a spleno-hepatic arterial anastomosis or a graft or prosthetic material interposition.

Postoperative Lymphorrhagia- a Possible Complication Following Cephalic Duodenopancreatectomy

Abstract Surgery associated with lymphadenectomy may sometimes result in a lymphorrhagia, which usually resolves spontaneously within a few days, sometimes becoming a refractory complication to the treatment. In the case of large flows, particular attention should be paid to hydro-electrolytic and protein losses. We present the case of a patient with persistent lymphorrhagia after a cephalic duodenopancreatectomy for a pancreatic head tumor. From the 5th postoperative day, the patient had a milky-like secretion on the subhepatic drainage tube. The discharge rate was variable, between 500 and 1500 ml per day, requiring parenteral administration of amino acids, plasma and electrolyte solutions. The postoperative progression was slowly favorable, with the patient discharge on the 25th day following surgery. There are several treatment options for a lymphorrhagia following an extended lymphadenectomy, from intensive parenteral therapy to peritoneal-venous shunt or ligation of the lymphatic vessel responsible for the production of lymphorrhagia. In this case the conservative treatment had a favorable result.

Exploration of peripancreatic lymphatic pathways in a live porcine model

Pancreatic cancer is associated with a poor prognosis, mainly due to lymph node invasion and lymph node recurrence after surgical resection, even after extended lymphadenectomy. The peripancreatic lymphatic system is highly complex and the specific lymphatic drainage of each part of the pancreas has not been established.The aim of this study was to determine the lymphatic drainage pathways specific to each part of the pancreas on live pigs using Patent Blue.The pancreases of 14 live pigs were injected in different parts of the gland. The technique was efficient and reproducible. The diffusion patterns were similar for each location and were reported. Our results in pigs allowed us to define specific nodal relay stations and lymphatic drainage for each part of the pancreas and confirm that independent anatomical-surgical pancreatic segments can be described. It is interesting to note that lymphatic drainage for the upper part of the proximal part of pancreas (duodenal lobe) occurred on the left side of the portal vein. This suggests that lymph node resection during cephalic duodenopancreatectomy in humans should be extended to the left side of the mesenteric vein, and probably to the right side of the superior mesenteric artery, as recently suggested.These results could help surgeons perform safe anatomical-segmental pancreatic resections with accurate lymphadenectomies and improve survival in patients with pancreatic cancer. Based on these results we will perform an innovative prospective study. Patent Blue will be injected into different parts of the gland in patients operated for pancreatic resection, and lymphatic diffusion of the dye will be recorded in relation to their origin from the theoretical pancreatic segments (ClinicalTrials.gov Identifier: NCT03597230).

Survival, morbidity and mortality of pancreatic adenocarcinoma after pancreaticoduodenectomy with a total mesopancreas excision

pancreatic adenocarcinoma is the most common malignancy in the periampullary region, with a five-year survival rate around 20%. the goal of our study was to determine the survival and safety data of a number of patients that underwent a cephalic duodenopancreatectomy (CDP) with total mesopancreas excision (TMPE). a prospective observational study was performed of 114 patients with pancreatic adenocarcinoma who underwent duodenopancreatectomy and TMPE over the period 2008-2017. Demographic variables, tumor stage, number of lymph nodes excised, lymph node ratio, R classification, the prognostic factor disease-free interval and survival were all assessed in a multivariate analysis. complications were reported for 54 (47.3%) patients, of which 22 (19.3%) were categorized as serious. The mortality rate was 4.3% and the mean follow-up was 26.2 months. During this period, 73 (64%) patients relapsed after a mean interval of 40.9 months. The relapse pattern was mainly hepatic (26.3%), followed by local relapse (20%). Mean survival was 40.38 and actuarial survival was 26.6% at five years. Relapse-related factors included stage T3 or higher (RR 8.1 [1.1-61]) and an R1 resection (RR 13.4 [2.7-66.5]) and survival-related factors included an R1 resection (RR 10.7 [2.5-46.2]). TMPE ensures an adequate lymphadenectomy and lymph node ratio according to reported standards. The survival of patients that have undergone surgery for pancreatic adenocarcinoma in our institution is 68.4% at one year and 26.6% at five years. An R1 resection is the primary factor for both relapse and survival.

Outcome after surgery for solid pseudopapillary pancreatic tumors in children: Report from the TREP project-Italian Rare Tumors Study Group.

Solid pseudopapillary pancreatic tumors (SPPT) are an extremely rare entity in pediatric patients. Even if the role of radical surgical resection as primary treatment is well established, data about follow-up after pancreatic resection in children are scant. A retrospective review of data from the Italian Pediatric Rare Tumor Registry (TREP) was performed. Short-term (<30 days) and long-term complications of different surgical resections, as well as long-term follow-up were evaluated. From January 2000 to present, 43 patients (male:female=8:35) were enrolled. The median age at diagnosis was 13.2 years (range, 7-18). Nine children had an incidental diagnosis, whereas 26 complained of abdominal pain and 4 of palpable mass. Tumors arose either from the head of pancreas (n=14) or from body/tail (n=29): only one patient presented with metastatic disease. Resection was complete in all patients (cephalic duodenopancreatectomy vs distal resection). At follow-up (median, 8.4 years; range, 0-17 years), one recurrence occurred in a patient with intraoperative rupture. All patients are alive. Three pancreatic fistulas occurred in the body/tail group, whereas four complications occurred in the head group (one ileal ischemia, two stenosis of the pancreatic duct, and one chylous fistula). Surgery is the best therapeutic option for these tumors; hence, complete resection is mandatory. Extensive resections, including cephalic duodenopancreatectomy, are safe when performed in specialized centers. Long-term follow-up should be aimed to detect tumor recurrence and to evaluate residual pancreatic function.

Abstract 3857: Patient-derived tumor xenografts as pharmacological model of human pancreatic ductal adenocarcinoma

Abstract INTRODUCTION and AIM Pancreatic ductal adenocarcinoma is a lethal disease with an overall survival rate of 5% and a median survival time of less than 6 months. Current systemic treatments offer only a modest benefit in symptom control and survival, thus surgery remains the most effective treatment. The exploitation of new therapeutics is an urgent need, but the research is braked by the limited value of the current preclinical models as predictors of patients response. The aim of our study is to develop patient-derived primary pancreatic ductal adenocarcinoma xenografts (PDAC-PDX) growing into the pancreas of recipient mice that retain features of the patient’s tumors and mimic the biological heterogeneity of human pancreatic cancer. METHODS Cancer specimens from patients undergoing cephalic duodenopancreatectomy were transplanted in NSG mice and orthotopically propagated by their re-implantation into the pancreas of SCID mice. Tumor burden was measured by abdominal palpation and by non invasive magnetic resonance imaging (MRI). PDAC-PDXs were characterized histologically, for mutational status (KRAS, TP53 and SMAD4), and responsiveness to gemcitabine. Gemcitabine was administered alone or combined with nab-paclitaxel, to mice bearing tumor in their pancreas; drugs were given intravenously on days 1 and 8 of each 21-day cycle to copy as much as possible patient’s recommendations. To determine the antitumor effects of the treatments, changes in tumor growth over time were evaluated by MRI and plasma level of Ca19-9. RESULTS Surgically resectable pancreatic adenocarcinoma (histologically confirmed) engrafted successfully in 5 cases (out of 11) and retained the molecular, morphological and biological features of the original patient tumors. Mutational landscape of the PDAC-PDXs reflect the clinical scenario: 80% are mutated in KRAS (G12D, G12R), 80% carry a TP53 mutation (I162F, R213*, Y220C, R248Q) and 20% show the deletion of SMAD4. Histological features recapitulate the human disease, the PDAC-PDXs exhibit a robust amount of host derived stroma with collagen deposition, constant through generations (up to five). Orthotopic growing PDAC-PDXs were marginal responsive to gemcitabine treatment, while significant response (stable disease and regression) was observed with the gemcitabine and nab-paclitaxel combination regimen, which was more efficacious than paclitaxel (equimolar dose). CONCLUSION PDAC-PDXs growing orthotopically in the pancreas of mice provide a valuable tool for the preclinical exploitation of novel therapeutics for pancreatic cancer. . Supported by Associazione Italiana per la Ricerca sul Cancro (AIRC 5 per mille n. 12182) and Fondazione “Eugenio Morandi” ONLUS per lo studio e la cura dei tumori del pancreas. Citation Format: Alessia Anastasia, Andrea Resovi, Carmen Ghilardi, Roberta Avigni, Edoardo Micotti, Lucia Minoli, Eugenio Scanziani, Carlo Corbellini, Eugenio Morandi, Dorina Belotti, Raffaella Giavazzi, MariaRosa Bani. Patient-derived tumor xenografts as pharmacological model of human pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3857. doi:10.1158/1538-7445.AM2017-3857

Early liver metastases in resectable periampullary cancer: Incidence and risk factors

PurposeThe aim of the present study was to estimate the incidence of very early hepatic metastases (HMs) (<6 months) and their imaging patterns after cephalic duodenopancreatectomy (CDP) for periampullary carcinoma (excluding duodenal carcinoma) and to identify their associated risk factors. MethodsFrom January 2003 to June 2016, all patients who underwent surgical treatment for periampullary carcinoma by CDP at our institution and with adequate pre- and postoperative CT scans were included. Univariate and multivariate logistic regressions were performed to determine factors associated with very early HM and recurrence. ResultsOf the 132 patients included retrospectively, 27 (20.5%) patients developed HMs. The mean time to diagnosis of HM was 103.9±55.2days. HMs were multiple in 81.4% of cases and bilobar in 59.3% of cases; their mean maximum size was 16.7±12.7mm.In univariate logistic analysis, lymphovascular emboli were significantly associated with HM (p=0.02). No independent risk factors for HM were found in multivariate analysis. In multivariate logistic analysis, two independent risk factors were identified for the occurrence of early recurrence: tumor size >23mm on preoperative CT scan (OR: 3.3; 95% CI: [1.2–9.3]; p=0.02) and tumor differentiation (poor vs. good: OR 15.5; 95 CI [1.5–158.3]; moderate vs. good: OR: 17.1; 95% CI: [1.9–154.4]; p=0.04). ConclusionsNearly one in five patients developed HM after CDP within 6 months with a highly consistent pattern. A thorough preoperative assessment, combining CT scan and MRI with a delay of less than three weeks before surgery, appears essential. A routine systematic postoperative CT scan at 8 weeks is also required prior to initiating adjuvant chemotherapy.The type of surgical intervention does not seem to be a risk factor, although the risk of HM occurrence appears to be related to the lymphovascular invasion of the tumor and maybe its degree of differentiation, elements not assessable by imaging.

Un cystadénocarcinome séreux du pancréas dans une variante solide

Cystic pancreatic neoplasms concern 1 to 2% of the pancreatic tumours. The serous ones are considered benign tumours but since 1989, several pancreatic serous cystadenocarcinomas (SCAC) cases have been reported. We report the case of a SCAC with a particular pattern. An 80-year-old female patient presented a 4-cm tumour in the neck of the pancreas associated with liver lesions evoking, on imagery exams, focal nodular hyperplasia nests. A cephalic duodenopancreatectomy and a resection of the liver lesions were carried out. The gross exam showed a tumour with a pattern mostly solid and an area made of cysts. The microscopic exam displayed two patterns: the solid one, predominant, made of mild atypical clear cells, and the cystic one. The liver lesions revealed solid pattern similar to the pancreatic tumour one. The tumoral cells were cytokeratin 7, AE1/AE3 and inhibin positives. The Periodic-acid Schiff showed cytoplasmic granulations, which were digested after diasatasis. Only the presence of metastases allows distinguishing a pancreatic serous cystadenoma from a SCAC. To date, thirty cases of pancreatic SCAC have been reported. Immunohistochemistry cannot confirm the malignancy nature of the lesion but it needs to be done in order to cross out the differential diagnosis, that is pancreatic metastatic clear cell renal carcinoma. Nevertheless, it remains a pathology with good prognosis. Only two cases have been reported but ours case a predominant solid pattern.

Pancreatico-gastric Anastomosis Following Cephalic Duodenopancreatectomy: New Perspectives

Abstract Introduction. Although in recent years there have been various versions of pancreatic - digestive reconstruction after cephalic duodenopancreatectomy, this issue is still highly debated. Purpose. This paper aims at comparing postoperative outcomes after gastric pancreatic anastomosis using transfixing threads as opposed to the purse-string suture method. Material and methods. Our study consisted of a lot of 15 patients that underwent cephalic duodenopancreatectomy from the 1th of May 2014 to the 30th of April 2015. The pancreatico - digestive reconstruction was done by pancreatico-gastric anastomosis using three different techniques: double purse-string suture used for the patients in the first group (group 1, n = 5 patients); one purse-string suture and 2 transfixing “U-sutures” passed through the stomach and the pancreas for the patients in the second group (group 2, n = 5 patients) and ductomucosa anastomosis with pancreatico-gastric transfixing threads in the third group (group 3, n = 5 patients). Results. Morbidity was 40% for the entire lot. Pancreatic fistula, occurred in two patients, one type A fistula in a patient in group 2 and one type B fistula in a patient in group 3. Biliary fistula occurred in one patient in group 2. Mortality was at 13.3%. The median time to carry out the anastomosis in group 1 was 14 minutes, for patients in group 2, 20 minutes, and for patients in group 3, 25 minutes. Conclusions. Gastric pancreatic anastomosis using purse-string sutures is a feasible, safe and fast process which reduces complications due to transfixing pancreatic threads.

OP0011 Derivation of a biobank of pancreatic ductal adenocarcinoma xenografts

Background Pancreatic ductal adenocarcinoma is a lethal disease that remains one of the most resistant to traditional therapies. Despite advances in the understanding of the molecular mechanisms underlying pancreatic carcinogenesis, current systemic treatments offer only a modest benefit in symptom control and survival. Methods The aim of our study was to develop a panel of patient-derived pancreatic ductal adenocarcinoma xenografts that mimic the biological heterogeneity of human pancreatic cancer. 12 patients with pancreatic ductal adenocarcinoma underwent cephalic duodenopancreatectomy. Pancreatic ductal adenocarcinoma xenografts were transplanted, subcutaneously and directly into the pancreas, in SCID mice. Three xenografts (HUPA 4, 8 and 11) took root successfully and were established in pancreas and subcutaneously in the mice. Each mouse was treated with nab-paclitaxel and gemcitabine, given at the optimal dose (intravenous nab-paclitaxel [25 mg/kg] and intravenous gemcitacbine [150 mg/kg]) comparable to the human dosing regimen. Each tumour was then analysed by our pathologist. Findings Pancreatic xenografts were histologically and pharmacologically similar to the corresponding patient’s tumour. Each tumour showed desmoplastic stroma, rare mucosal glandular component, and resistance to combined therapy. Each tumour had a medium time of latency (time to reach 150 mm 3 ) of 50–60 days, a time to reach 250 mm 3 of 60–70 days, and a doubling time of 20 days. Interpretation This biobank of patient-derived pancreatic ductal adenocarcinoma xenografts could be useful to study the biology of pancreatic ductal adenocarcinoma and develop new treatments.

Over 6-year survival in locally advanced cholangiocarcinoma – a case report

Cholangiocarcinoma is a malignancy of the biliary duct system that may originate in the liver and extrahepatic bile duct. Despite aggressive anticancer therapy and interventional supportive care, the overall survival is approximatively 6 months, most patients not being eligible for curative resection. Case description: A 64 year-old patient, diagnosed in 2008 with locally advanced bile duct neoplasm (T3N0M0), who underwent latero-lateral hepatoduodenal anastomosis and cholecystectomy in 2008, followed by neoadjuvant Gemcitabine chemotherapy and cephalic duodenopancreatectomy with tumor exeresis in 2009, uncompliant to follow-up, presents with abdominal meteorism, diffuse abdominal pain, inappetence, weight loss and increased fatigability. Initial ultrasonography showed a localized pancreatic tumor and liquid in the Douglas pouch, both confirmed by CT scan. Discussion: The 6-year survival compared to the general mean survival rate of 17 months, depending on the type of the neoplasm, raises questions about the otherwise histopathology confirmed diagnosis of well differentiated cholangiocarcinoma. The present image documented pancreatic tumor makes the retrospective diagnosis assessment even more intricate. Slow-progressor outlier cases might represent new diagnostic entities, and their understanding can be instrumental in improving the therapeutic efficiency. Long time survival in such diagnostic entities is scarcely reported in literature.

Pancreas cancer-associated polymyositis of the legs regressing after cephalic duodenopancreatectomy: case report and review of the literature.

Inflammatory myopathy, such as polymyositis, has been widely reported as paraneoplastic syndrome associated with various malignancies. However, its association with pancreas adenocarcinoma is very uncommon. A case of a patient with paraneoplastic polymyositis of both legs associated with pancreatic adenocarcinoma is reported here. The diagnosis of polymyositis was highlighted by MRI and confirmed by histopathological examination. The surgical resection of the primary tumor led to the complete resolution of polymyositis with no further recurrence despite later metastases. The association between pancreatic cancer and paraneoplastic polymyositis is very uncommon and has to be recognized by clinicians.

Acute abdomen due to complicated intramural duodenal haematoma. Case report and literature review

Abstract Background Intramural duodenal haematoma is a rare entity that usually occurs in the context of patients with coagulation disorders. A minimum percentage is related to processes such as pancreatitis and pancreatic tumours. Clinical case The case is presented of a 45 year-old male with a history of chronic pancreatitis secondary to alcoholism. He was seen in the emergency room due to abdominal pain, accompanied by toxic syndrome. The abdominal computed tomography reported increased concentric duodenal wall thickness, in the second and third portion. After oesophageal-gastro-duodenoscopy, he presented with haemorrhagic shock. He had emergency surgery, finding a hemoperitoneum, duodenopancreatic tumour with intense inflammatory component, as well a small bowel perforation of third duodenal portion. A cephalic duodenopancreatectomy was performed with pyloric preservation and reconstruction with Roux-Y. Discussion Treatment of a duodenal haematoma is nasogastric decompression, blood transfusion and correction of coagulation abnormalities. Surgery is indicated in the cases in which there is no improvement after 2 weeks of treatment, or there is suspicion of malignancy or major complications arise. Conclusions Duodenal intramural haematoma secondary to chronic pancreatitis is rare, although the diagnosis should be made with imaging and, if suspected, start conservative treatment and surgery only in complicated cases.

Embolization of a Jejunal Artery Pseudoaneurysm via Collateral Vessels.

Visceral artery pseudoaneurysms are rare and only few cases have been reported. They are considered to be life threatening in case of rupture. Rapid treatment is mandatory and endovascular procedure is recommended as the treatment of choice. Occasionally, endovascular approach is difficult to achieve, owing to unusual vascular anatomy. Whenever it is the case, an alternative method has to be considered. We report the case of a jejunal artery pseudoaneurysm that required an access via collateral vessels to accomplish complete occlusion in a 34-year-old woman who presented with a sudden epigastric pain 14 days after a cephalic duodenopancreatectomy.