Duodenal Lumen Research Articles

Mutant KRAS and GNAS DNA Concentrations in Secretin-Stimulated Pancreatic Fluid Collected from the Pancreatic Duct and the Duodenal Lumen.

Objectives:The analysis of secretin-stimulated pancreatic fluid is being evaluated as an approach to improve the early detection of pancreatic cancer and pancreatic precursor neoplasms. The method of pancreatic fluid sampling may have a significant impact on tumor marker measurements. The aim of this study was to compare concentrations of mutant DNA in pancreatic fluid from patients who had samples collected from both the pancreatic duct and duodenal lumen.Methods:Thirty-six participants enrolled in the Cancer of the Pancreas Screening studies at Johns Hopkins Hospital who had secretin-stimulated pancreatic fluid collected from the duodenum during endoscopic ultrasound (EUS) and from the pancreatic duct during subsequent endoscopic retrograde cholangiopancreatography. Mutant KRAS and GNAS DNA concentrations were measured in pancreatic fluid samples using digital high-resolution melt-curve analysis and pyrosequencing and were related total DNA concentrations in these samples.Results:Thirty-four patients had subtle parenchymal abnormalities by EUS; seven had small pancreatic cysts; none had pancreatic cancer. KRAS mutations were detected in 29 of 36 (80.6%) pancreatic duct fluid samples. Of these 29 patients, 23 had mutations detected in their duodenal fluid (79.3%). Patients with detectable pancreatic fluid but not duodenal fluid KRAS mutations had lower average pancreatic duct fluid KRAS mutation concentrations (P=0.01). Patients with KRAS or GNAS mutations detected in pancreatic fluid but not duodenal fluid had higher total DNA concentrations in their duodenal compared with pancreatic fluid (P=0.03). KRAS and GNAS mutation concentrations were higher in pancreatic duct fluid samples than in matching duodenal fluid samples (for KRAS: 2.62 vs. 0.39%, P<0.0001).Conclusions:KRAS and GNAS mutation concentrations are significantly lower in secretin-stimulated pancreatic fluid samples collected from the duodenum compared with samples collected from the pancreatic duct. Efforts to improve the purity of pancreatic fluid collections from the duodenum could improve the detection of mutations arising from the pancreas.

More Than Skin Deep

Introduction: A 47-year-old female without significant past medical history presented to her PCP with complaints of generalized pruritus for 3 weeks. She had previously been evaluated at an urgent care facility where she was given a course of steroids for her symptoms. Although she had brief improvement with prednisone, her symptoms returned after the course ended. She denied any other systemic symptoms specifically weight loss, fever/chills, nausea/vomiting, or change in bowel habits. She had recently noticed darkening of her urine and possible jaundice, but stated this seemed to be improving. Her physical exam was notable for jaundice without evidence of chronic liver disease. Her abdomen was soft, non-tender, and she had no lymphadenopathy. Laboratory evaluation showed AST 166 IU/L, ALT 90 IU/L, total bilirubin 8.4 mg/dL, and alkaline phosphatase of 401 IU/L. A computed tomography (CT) scan revealed diffuse dilation of intrahepatic ducts and a 1.5-cm common bile duct (CBD), as well as 4.8 x 6.7 cm heterogeneous mass in the gallbladder with a second similarly enhancing lesion seen at the distal CBD. The pancreas appeared normal. An ERCP was performed which revealed a polypoid appearing mass within the distal bile duct. A biliary sphincterotomy was performed and this was biopsied after eversion into the duodenal lumen. Initial differential included biliary cystadenoma/adenocarcinoma versus atypical cholangiocarcinoma versus lymphoma or IPMN of the bile ducts. However, biopsy specimen showed pigmented deposition on H&E stain with subsequent positive staining for S-100 and HMB proteins consistent with melanoma. Unfortunately, a staging MRI of the brain showed evidence of metastatic lesions. Thorough skin, eye, and mucosal examination did not reveal evidence of a primary lesion, and a CT-PET scan showed large, hypermetabolic lesions in the gallbladder and distal bile duct without evidence of other primary source. Therefore, our final diagnosis is primary biliary melanoma with metastatic disease to the brain. Only 10 other cases of primary biliary melanoma have been reported in the literature to date. Mortality is based on stage of disease at presentation with surgical resection providing the best chance for survival. Unfortunately, our patient had metastases present at diagnosis and was not a candidate for surgery. In the 6 months since diagnosis, she has been treated with radiation and Anti-CTLA 4 therapy and is undergoing evaluation for inclusion in clinical trials.

Anatomy and Surgical Management of Ampullary Neoplasm

Ampulla is a common channel where biliary and pancreatic duct join. The reason why it is called ampulla is that this area is enlarged where it penetrates the duodenal wall. As it protrudes into the duodenal lumen, it is also called papilla. Ampulla is surrounded by sphincter muscles which control the secretion of bile and pancreatic juice. Ampullary tumor includes broad spectrum of benign and malignant tumors which need different treatment options - Endoscopic papillectomy (EP), surgical ampullectomy (SA), and pylorus-preserving pancreatoduodenectomy (PPPD). There is a consensus that benign tumors need EP and malignant tumors need PPPD. However, there are controversies regarding how to treat high-grade dysplasia (HGD), carcinoma in-situ, or T1 cancer. Surgical treatment includes SA and PPPD. The indication of SA is usually benign tumors which extend to bile duct or pancreatic duct or too big tumors to snare completely by endoscopy. Compared to EP, SA is less likely to leave remnant tumor which results in re-resection. In some limited cases of early carcinoma, SA can be attempted. Oncologically, however, SA is not recommended because there might be incomplete resection, lymph node metastasis, lymphovascular invasion, or perineural invasion. As PPPD still has high morbidity, prolonged length of stay, and relatively high post-op mortality, SA can be recommended in old patients with co-morbidity that can be exacerbated after surgery. Technically important points of SA are as follows; first, resecting the whole layer of duodenum, second, re-implanting the bile duct and pancreatic duct with duodenal mucosa to keep the mucosal continuity. PPPD is a standard operation of malignant tumor because it can completely remove the tumor as well as regional lymph nodes. Keywords: Ampullary neoplasm, Anatomy, Surgery Keywords: 팽대부 ì¢ ì–‘, 해부학, 수ìˆ

Confocal Endomicroscopy Identifies Loss of Local Barrier Function in the Duodenum of Patients with Crohnʼs Disease and Ulcerative Colitis

Increased cell shedding with gap formation and local barrier dysfunction can be identified endomicroscopically in the terminal ileum of patients with inflammatory bowel disease. We aim to evaluate whether these changes are also present in the duodenum of patients with inflammatory bowel disease. Fifteen patients with Crohn's disease (CD), 10 patients with ulcerative colitis (UC), and 10 controls underwent fluorescein-aided confocal laser endomicroscopy (CLE). CLE was performed on macroscopically normal antral and duodenal (D1, D2, D3, D4) mucosa. Representative CLE images were prospectively analyzed. Images were scored for the number of epithelial gaps, cell shedding, and the degree of fluorescein leakage into the intestinal lumen. Both CD and UC patients had significantly more epithelial gaps, epithelial cell shedding, and leakage of fluorescein into the duodenal lumen than controls. The degree of cell shedding and epithelial gap formation was similar in CD and UC patients. In all cases, macroscopic endoscopic appearances of the duodenum were normal, and conventional histological analysis showed a mild nonspecific duodenitis in 7 of 15 patients with CD. Patients with UC had a histologically normal duodenum. Gap formation, cell shedding, and fluorescein leakage was similar in CD with active compared with inactive disease, except for D2 shedding. CLE can detect epithelial damage and barrier loss in the duodenum of CD and UC patients that is not apparent on conventional endoscopy or histology.

Double duodenal atresia noticed as an intraabdominal cyst in the fetus

Double duodenal atresia is a rare disease and twenty-two cases have been reported in the English literature. We report here a case of double duodenal atresia that had been suspected by fetal ultrasonography as polyhydramnios and a large cyst at the right upper abdomen. Two membranous diaphragms at the duodenum separated the duodenal lumen and formed a cystic lesion. Surgical reconstruction was performed.

A Case of Choledochocele Unclassifiable by Sarris?s Classification Characterized by the Serial Images of Endoscopic Retrograde Cholangiopancreatography [ERCP

A 74-year-old Japanese housewife was shown to have a large, smooth-surfaced, protruding, subpedunculated tumor covered with the normal-appearing mucosa on the posteromedial wall of the mid descending part of the duodenum immediately oral to the papilla of Vater by endoscopy. ERCP demonstrated the normal main and accessory pancreatic ducts. Just after abruptly contracted, the terminal common bile duct [CBD] showed a piriform dilatation correspondent to the duodenal tumor and tapered off to drain into the duodenal lumen without forming a common channel but through the same papillary orifice with the main pancreatic duct [MPD]. She was diagnosed with choledochocele unclassifiable by Sarris’s categorization. Even fully distended by infusion of contrast medium, the cyst did not compress the MPD. Remaining asymptomatic, the lesion was left untreated. She has kept an uneventful course for 4 years ever since. It is important to characterize the topographic relationships of the cyst among the surrounding structures in order to definitely classify the anomaly and to predict development of probable complications by analyzing the serial images of ERCP.

Evaluation of repair in duodenal perforation with human amniotic membrane: An animal model (dog).

Background:There is a growing tendency toward application of human amniotic membrane (HAM) as a biologic substitute in various tissue injuries where a significant tissue loss is a matter of concern. In gastrointestinal injuries especially duodenal ones, some potential limitations in current surgical techniques contribute to not fully acceptable healing outcomes. Thus, this study was carried out to assess repair with HAM patch for duodenal defect in comparison with simple duodenoraphy in an animal model (dog).Materials and Methods:A total of 15 male German shepherd dogs weighing 23-27 kg were randomly divided into two groups. Group A with 10 dogs, which were a candidate for duodenal repair by amniotic membrane patch and Group B consisted of 5 dogs perform simple duodenorraphy. A precise control was made to match all conditions except surgical technique. Macroscopic and microscopic features of the healed duodenal lumen in both groups were recorded.Results:Gross evaluation revealed no difference in luminal diameter in both groups. Statistical analysis of duodenal diameter between both groups after operation also showed no significant difference (Pv = 0.789). Histological assessment indicated less inflammation with better wound healing in Group A.Conclusion:It seems that repairing duodenal wall defect with HAM would result in better histological outcomes compared with what is seen in simple duodenoraphy in animal models. However, there is no significant difference regarding surgical findings.

Groove pancreatitis presenting as recurrent acute pancreatitis

A middle aged male presented with recurrent acute pancreatitis without any feature of extrahepatic biliary obstruction. Evaluation revealed mass in groove area with duodenal lumen compromise without any features of chronic pancreatitis. He underwent classical Whipple's operation with the suspicion of periampullary tumor but histopathology was suggestive of groove pancreatitis ruling out malignancy. This case is first case to report recurrent acute pancreatitis as presentation of groove pancreatitis.

Giant villous duodenal adenoma with malignant change: an unusual cause of obstructive jaundice

Obstructive jaundice can have various causes, and both neoplastic and non-neoplastic lesions have to be considered. In cases of malignant disease, the tumors are usually located in the extrahepatic bile ducts, the pancreatic head, or the ampulla of Vater [1]. In rare cases, the causative lesion originates from the duodenum [2,3]. A 67-year-old man presented with nonspecific right upper quadrant pain and icterus. Laboratory analysis revealed marked cholestasis: alkaline phosphatase 607U/L (normal 35–129U/L), gamma glutamyltransferase 1595U/L (normal 0– 66U/L), and total bilirubin 27.2mg/dL (normal 0–1mg/dL). At endoscopy, a huge villous duodenal adenoma was detected, which covered almost the entire duodenal wall (● Fig.1). Intubation of the ampulla of Vater was impossible. A computed tomography (CT) scan showed an irregular, polypoid tumor that was protruding into theduodenal lumen, butwas confined to the bowelwall (● Fig.2). The pancreaticoduodenectomy specimen subsequently showed an intraduodenal villous tumor measuring 12.5cm in its largest diameter. The cut surface of the ampulla was firm, yellow–white, and suspicious of malignancy (● Fig.3). This area measured 1.5cm in its largest diameter. Histology revealed a villous adenoma (with low and high grade dysplasia) with progression to poorly differentiated ampullary adenocarcinoma that was invading both the pancreas and the peripancreatic soft tissue (● Fig.4). Seven regional lymph node metastases were identified. The patient’s postoperative course was uneventful and he was discharged in good condition 10 days after surgery. Villous adenomas of the duodenum have a predilection for the ampullary region, tend to present with obstructive jaundice, especially if malignancy is present, and Fig.1 Endoscopic view showing a circumferential villous adenoma carpeting almost the entire duodenal wall. Fig.2 Abdominal computed tomography (CT) scan showing an irregular polypoid tumor mass protruding into the duodenal lumen (arrows).

Giant Inflammatory Pseudopolyp of the Duodenum

Purpose: Duodenal polyps are an uncommon finding. Typically, duodenal polyps are frequently seen in patients with genetic syndromes such as familial adenomatous polyposis syndrome, but also may occur sporadically. Unless large enough to cause symptoms, duodenal polyps are often discovered incidentally on upper endoscopy. Once discovered, therapeutic management depends on patient symptoms, histology, and/or size of the polyp. Management may include observation, endoscopic removal, or surgery. Here, we present a case of an unusually large duodenal pseudopolyp with unique histological features. We describe the management and course of the polyp over a 3-year time period. A 59-year-old male with a past medical history significant for prior myocardial infarction, diabetes and hyperlipidemia was referred by his gastroenterologist for evaluation of a large 4 cm duodenal polyp (not involving the ampulla) that encompassed one half the circumference of his duodenal lumen. Approximately 2 weeks prior, he underwent an upper endoscopy for an upper gastrointestinal bleed (attributed to a small gastric vessel) at which time this large polyp was incidentally discovered. Review of outside pathology reports were concerning for an adenomatous polyp with low-grade dysplasia. Upon review of the biopsy specimen by a pathologist at our institution, the polyp was found to consist of benign small bowel mucosa with non-specific inflammatory and reactive epithelial atypia with no definitive dysplasia. Due to the concerning size of this duodenal polyp, the patient subsequently underwent an MRI and upper endoscopy. MRI revealed no extra duodenal involvement and once again, biopsy revealed benign duodenal mucosa with chronic inflammation and reactive changes with no dysplasia. Following these investigational tests, general surgery was subsequently consulted for recommendations concerning surgical management. Due to the benign histology of the polyp, conservative measures with close observation were recommended. Thus, a follow up EGD with EUS was performed 8 weeks later. EUS demonstrated slight involvement of the submucosa and histology revealed reactive and regenerative changes with no malignancy. The patient continued to have regular surveillance with five upper endoscopies over the past 3 years. His most recent endoscopy has revealed a significant reduction in polyp size with biopsy showing benign mucosa, normal villous architecture and no active inflammation. There has been no progression to dysplasia or malignancy. This case highlights an unusual finding of a giant inflammatory pseudopolyp with unique histological features and the role of conservative management.

A Fortuitous Diagnosis of Pancreas Divisum Using Endoscopic Ultrasound Guided Rendezvous Access

Purpose: Pancreas divisum is the most common pancreatic congenital anomaly wherein the smaller ventral ducts drains through the larger major papilla and the larger dorsal duct drains through the smaller minor papilla. It is present in 7% of the general population with 5% develop symptoms. We present a case of unexpected diagnoses of pancreas divisum using endoscopic ultrasound (EUS) guided rendezvous pancreatic duct (PD) access. Methods: A 65-year-old Caucasian lady with history of hypertension and prior cholecystectomy was referred to our institution with a history of four episodes of recurrent acute pancreatitis (AP) over a span of 6 years. Patient underwent multiple CT scans and an MRI of her abdomen which were all reported normal. Initial endoscopic ultrasound (EUS) done about a year ago revealed chronic pancreatitis changes. ERCP with limited sphincterotomy (due to a large periampullary diveritculum) revealed microlithiasis. Results: Despite biliary sphincterotomy, patient developed another episode of AP. Repeat MRI from the referring hospital revealed a diffusely dilated PD (0.5 cm). Repeat ERCP was unsuccessful in PD cannulation. Patient returned for an EUS guided rendezvous PD access. Under EUS guidance, the PD was accessed and a guidewire was passed anterogradely into the duodenal lumen. Surprisingly the guidewire was noted to be coming out of the minor papilla raising suspicion of pancreas divisum. An endoscopic retrograde pancreatogram confirmed the presence of complete pancreatic divisum. Given this finding, minor papillary sphincterotomy with stent placement was performed. Patient thus far has not had further episodes of pancreatitis. Conclusion: Discussion: Pancreas divisum is the most common pancreatic congenital anomaly resulting in recurrent AP. The diagnosis of pancreas divisum is usually made by endoscopic retrograde cholangiopancreatography (ERCP) in patients presenting with pancreatobiliary symptoms. It was significantly more common in patients presenting with idiopathic pancreatitis (up to 50 percent) than in controls or in the general population. This case has multiple interesting points. In the absence of alcohol use and gallstone disease, recurrent AP should raise the suspicion for anatomic variations (mainly pancreas divisum), medications, etc. Diagnosis of pancreas divisum was missed despite multiple imaging studies and finally obtaining pancreatogram via EUS guided rendezvous PD access confirmed the diagnosis.Figure

An intragastric chest tube insertion

A 38-year-old man presented with a 1-week history of respiratory distress and abdominal pain with vomiting. He had undergone left lower lobectomy for localized bronchiectasis 6 months earlier. Physical examination revealed unilateral distension of the left thorax with hyperresonance to percussion and absent breath sounds suggestive of left tension pneumothorax. He rapidly presented cardiopulmonary arrest. Early resuscitation was provided but needle aspiration was unsuccessful. Return to spontaneous cardiac activity was obtained after left chest tube insertion and pleural drainage of 1,000 ml of brown fluid and gas. A chest radiograph (Fig. 1) performed before cardiac arrest showed air and liquid in the left pleural cavity with severe deviation of mediastinal structures and right lung compression. A CT-scan (Fig. 2) of the chest revealed herniation of the stomach into the left chest cavity and insertion of the chest tube into the lumen of the intrathoracic stomach. An urgent surgical procedure established the diagnosis of acquired diaphragmatic hernia with intrathoracic gastric volvulus. Perioperative findings confirmed gastric placement of the tube with its trans-diaphragmatic route until the duodenal lumen. Surgery consisted of replacing the stomach back into the abdomen, suturing the iatrogenic gastric perforation, and repairing the diaphragm.

Secretion of Protective Antigens by Tissue-Stage Nematode Larvae Revealed by Proteomic Analysis and Vaccination-Induced Sterile Immunity

Gastrointestinal nematode parasites infect over 1 billion humans, with little evidence for generation of sterilising immunity. These helminths are highly adapted to their mammalian host, following a developmental program through successive niches, while effectively down-modulating host immune responsiveness. Larvae of Heligmosomoides polygyrus, for example, encyst in the intestinal submucosa, before emerging as adult worms into the duodenal lumen. Adults release immunomodulatory excretory-secretory (ES) products, but mice immunised with adult H. polygyrus ES become fully immune to challenge infection. ES products of the intestinal wall 4th stage (L4) larvae are similarly important in host-parasite interactions, as they readily generate sterile immunity against infection, while released material from the egg stage is ineffective. Proteomic analyses of L4 ES identifies protective antigen targets as well as potential tissue-phase immunomodulatory molecules, using as comparators the adult ES proteome and a profile of H. polygyrus egg-released material. While 135 proteins are shared between L4 and adult ES, 72 are L4 ES-specific; L4-specific proteins correspond to those whose transcription is restricted to larval stages, while shared proteins are generally transcribed by all life cycle forms. Two protein families are more heavily represented in the L4 secretome, the Sushi domain, associated with complement regulation, and the ShK/SXC domain related to a toxin interfering with T cell signalling. Both adult and L4 ES contain extensive but distinct arrays of Venom allergen/Ancylostoma secreted protein-Like (VAL) members, with acetylcholinesterases (ACEs) and apyrase APY-3 particularly abundant in L4 ES. Serum antibodies from mice vaccinated with L4 and adult ES react strongly to the VAL-1 protein and to ACE-1, indicating that these two antigens represent major vaccine targets for this intestinal nematode. We have thus defined an extensive and novel repertoire of H. polygyrus proteins closely implicated in immune modulation and protective immunity.

Endoscopic rendez-vous after damage control surgery in treatment of retroperitoneal abscess from perforated duodenal diverticulum: a techinal note and literature review

IntroductionThe duodenum is the second seat of onset of diverticula after the colon. Duodenal diverticulosis is usually asymptomatic, but duodenal perforation with abscess may occur.Case presentationWoman, 83 years old, emergency hospitalised for generalized abdominal pain. On the abdominal tomography in the third portion of the duodenum a herniation and a concomitant full-thickness breach of the visceral wall was detected. The patient underwent emergency surgery. A surgical toilette of abscess was performed passing through the perforated diverticula and the Petzer’s tube drainage was placed in the duodenal lumen; the duodenostomic Petzer was endoscopically removed 4 months after the surgery.DiscussionA review of medical literature was performed and our treatment has never been described.ConclusionFor the treatment of perforated duodenal diverticula a sequential two-stage non resective approach is safe and feasible in selected cases.

Duodenal penetration of an inferior vena cava filter: case report and literature review

The insertion of inferior vena cava filters (IVCF) is a well-known therapy used in the prevention of pulmonary embolism (PE). The incidence of IVCF-related complications is low and complete caval penetration of a filter with adjacent organ injury has a reported incidence of 0–1%. We report the case of an 18-year-old male who sustained a spinal cord injury after a motor vehicle crash. The patient received a prophylactic IVCF and subsequently presented with right flank pain, postprandial nausea, and vomiting. His exam was benign and a computed tomography scan revealed extra-caval penetration of the filter with struts within the duodenal lumen and psoas muscle. The patient underwent an exploratory laparotomy with extraction of the filter, inferior vena cava venorrhaphy, and repair of the duodenal injury. This complication illustrates the potential morbidity of a common procedure and emphasizes the importance of investigating the IVCF as a possible source of abdominal pain.

Presence of luminal acetate sensing and absorption mechanisms in rat duodenum

Duodenal lumen short‐chain fatty acids (SCFA) are derived from ingested food or bacteria. Since SCFA receptors GPR41 and 43 are expressed on duodenal endocrine cells, and since a selective GPR43 agonist increases duodenal HCO3− secretion (DBS) via muscarinic/5‐HT4 receptor activation, we further examined the effect of luminal acetate on DBS. We measured DBS with pH and CO2 electrodes in a perfused duodenal loop in anesthetized rats. GPR41 colocalized with glucagon‐like peptide (GLP)‐1, whereas GPR43 colocalized with 5‐HT. Luminal perfusion of acetate dose‐dependently increased DBS with increasing GLP‐2 release. Acetate‐induced DBS was reduced by the 5‐HT4 receptor antagonist GR113808, pretreatment with indomethacin or high‐dose capsaicin, or co‐perfusion of the monocarboxylate transporter (MCT) inhibitor 4‐CHCA. Na+‐coupled MCT‐1 (SMCT1) was localized on the brush border and MCT4 on the basolateral membrane of upper villous epithelial cells, whereas MCT1 was expressed on the basolateral membrane of lower villous and crypt cells. Feeding increased the membrane localization of MCT1 and 4 with increased mRNA expression, compared to overnight fasting. Luminal acetate‐induced DBS via GLP‐2, 5‐HT, prostaglandin and capsaicin pathways, and acetate absorption via SMCT1 and MCT, may be implicated in the pathogenesis of functional dyspepsia and bacterial overgrowth. VA Merit Review, NIH‐NIDDK R01 DK54221

Percutaneous Management of Postoperative Duodenal Stump Leakage with Foley Catheter

This study was designed to evaluate retrospectively the safety and efficacy of the percutaneous management of duodenal stump leakage with a Foley catheter after subtotal gastrectomy. Ten consecutive patients (M:F = 9:1, median age: 64 years) were included in this retrospective study. The duodenal stump leakages were diagnosed in all the patients within a median of 10 days (range, 6-20). At first, the patients underwent percutaneous drainage on the day of or the day after confirmation of the presence of duodenal stump leakage, and then the Foley catheters were replaced at a median of 9 days (range, 6-38) after the percutaneous drainage. Foley catheters were placed successfully in the duodenal lumen of all the patients under a fluoroscopic guide. No complication was observed during and after the procedures in all the patients. All of the patients started a regular diet 1 day after the Foley catheter placement. The patients were discharged at a median of 7 days (range, 5-14) after the Foley catheter placement. The catheters were removed in an outpatient clinic 10-58 days (median, 28) after the Foley catheter placement. Fluoroscopy-guided percutaneous Foley catheter placement may be a safe and effective treatment option for postoperative duodenal stump leakage and may allow for shorter hospital stays, earlier oral intake, and more effective control of leakage sites.

Pyloroduodenal Duplication Cysts: Treatment of 11 Cases

Abdominal enteric duplications are found in 1 out of 4,500 autopsies, and only 4 to 5% of them are located in the duodenum, where they may be connected with the biliary or pancreatic ducts. The aim of this study was to describe the clinical features, management, and outcome of a large series of duodenal duplication cysts. The charts of all patients treated at our institution between 1985 and 2011 were reviewed retrospectively with particular attention to imaging, surgical technique, pathology, and outcome. During that period, 11 cases (81.8% females) were treated. Out of the 11 patients, 8 were symptomatic (vomiting in 3, recurrent acute pancreatitis in 2, and abdominal pain in 3) and 3 were tentatively diagnosed prenatally as choledochal cysts. Median age at surgery was 2.3 years (0 to 13.7) and preoperative diagnosis was correct in five cases. Five cysts were developed intraluminally and three communicated with the biliary duct (one), pancreatic duct (one), or both (one). Surgical treatment consisted of complete resection (four cases, including one pancreaticoduodenectomy), partial removal including all mucosa (four cases), and internal marsupialization (three cases). In all cases, the ductal communications were divided and opened into the duodenal lumen. In six cases, ectopic gastric mucosa was found. All patients recovered uneventfully. Duodenal duplication cysts are rare and may have bizarre anatomical patterns due to biliopancreatic involvement. Optimal treatment is complete surgical removal, and, if this is not possible, partial removal including the mucosa or marsupialization are also good alternatives. In cases with biliary and pancreatic tract connections, these have to be taken down carefully and drained into the duodenum.

Intraductal papillary mucinous neoplasm penetrating to the stomach, duodenum, and jejunum demonstrated on MR cholangiopancreatography with an oral negative contrast agent

A 65-year-old man was referred to our hospital due to epigastric pain. Abdominal enhanced computed tomography (CT) demonstrated marked dilatation of the main pancreatic duct (MPD) and communication to the gastric and duodenal lumen was suspected. Esophagogastroduodenoscopy (EGD) showed a villous tumor with white mucous discharge in the posterior wall of the gastric corpus and duodenal bulb. Pathological specimens showed mucin-producing epithelium with nuclear atypia that had developed in a papillary form. Based on these findings, we diagnosed intraductal papillary mucinous neoplasm (IPMN) arising in the MPD with penetration into the gastric and duodenal lumen. Magnetic resonance cholangiopancreatography (MRCP) with an oral negative contrast agent (manganese chloride tetrahydrate) showed a fistulous tract not only to the stomach and duodenum, but also to the jejunum. MRCP demonstrated mucous streaming with remarkably high intensity. In this case, an oral negative contrast agent was useful to distinguish mucous discharge from gastric fluid, facilitating the diagnosis of penetration to the jejunum. This finding was unobtainable by CT or EGD. When IPMN penetrating to other organs is suspected, MRCP with an oral negative contrast agent may provide important information.

Ampullary Region Carcinomas

Ampullary (AMP) carcinomas comprise a heterogeneous group of cancers lacking adequate subcategorization. In the present study, 249 strictly defined primary AMP carcinomas (ACs) identified in 1469 malignant pancreatoduodenectomy specimens were analyzed for defining features. Gross and microscopic findings were used to determine tumor epicenter and extent of preinvasive component. ACs were classified into 4 distinct subtypes based on location: (1) Intra-AMP (25%): Invasive carcinomas arising in intra-ampullary papillary-tubular neoplasms with zero to minimal, duodenal surface involvement (<25% of the tumor). These tumors were more commonly found in men, they had a relatively large overall size (mean, 2.9 cm) but had smaller invasive component (mean, 1.5 cm), and were predominantly of a lower TNM stage (85%, T1/2; and 72% N0). They carried the best prognosis among the 4 groups (3-y survival, 73%). (2) AMP-ductal (15%): These were tumors forming constrictive, sclerotic, plaque-like thickening of the walls of the common bile duct and/or pancreatic duct resulting in mucosa-covered, button-like elevations of the papilla into the duodenal lumen. There was no significant exophytic (preinvasive) growth. These were the smallest tumors (mean overall size, 1.9 cm; mean invasion size 1.7 cm), but carried the worst prognosis (3-y survival, 41%), presumably due to the pancreatobiliary histology/origin (in 86%); however, even this group had significantly better prognosis when compared with 113 ordinary pancreatic ductal adenocarcinomas (3 y, 11%; P<0.0001). (3) Peri-AMP-duodenal (5%): Massive exophytic, ulcero-fungating tumors growing into the duodenal lumen and eccentrically encasing the ampullary orifice with only minimal intra-ampullary luminal involvement. These were mostly of intestinal phenotype (75%) and some had mucinous features. Although these tumors were the largest (mean overall size 4.7 cm; and mean invasion size 3.4 cm), and had the highest incidence of lymph node metastasis (50%), they carried an intermediate prognosis (3-y survival, 69%) to that seen among a group of 55 nonampullary duodenal carcinoma controls. (4) AC-not otherwise specified ("papilla of Vater"; 55%): Ulcero-nodular tumors located at the papilla of Vater, which do not show the specific characteristics identified among the other 3 subtypes. In conclusion, ACs comprise 4 clinicopathologic subtypes that are prognostically distinct.