Ectopic Pancreatic Tissue Research Articles

Low Grade Pre-malignant Lesion of Pancreatic Rest in Stomach, Surveillance a Dilemma

INTRODUCTION: Pancreatic intraepithelial lesions (PanIN) are premalignant lesions of pancreatic ductal adenocarcinoma (PDA). PanIN and PDA found in ectopic gastric pancreatic rest tissue are extremely rare, with only two cases of low-grade PanIN in ectopic gastric ectopic pancreatic tissue reported. In this case report, we present a case of PanIN in gastric ectopic pancreatic tissue found after lesion removal by endoscopic mucosal resection (EMR). CASE REPORT: A 47-year-old female with no significant history underwent an upper endoscopy for abdominal pain. Upper endoscopy revealed gastritis in the stomach and a 1 cm subepithelial lesion with central umbilication in the gastric antrum (figure 1). Endoscopic ultrasound examination revealed that the lesion was arising and limited to only the submucosa. EMR was performed to remove the lesion en bloc (figure 1). Pathological examination revealed gastric heterotopic pancreatic tissue and focal pancreatic intraepithelial neoplasia 1A (figure 2). Follow-up surveillance endoscopy performed at 6 months revealed no evidence of recurrence (figure 3).Figure: Endoscopic image showing (Left) A 1 cm submucosal polyp with central umbilication in the antrum. (Middle) Post en-block removal of polyp by endoscopic mucosal resection technique. (Right) Lesion closed with 2 clips.Figure: Histopathologic examination of haematoxylin and eosin stained pancreatic rest tissue specimen under x400 shows that pancreatic duct is lined by a single layer of epithelium with abundant apical mucinous cytoplasm and basal nuclei that lack atypia consistent with Pancreatic Intraepithelial Neoplasia 1A.Figure: Endoscopic image showing a scar tissue in the antrum from prior intervention with no residual pancreatic rest tissue.DISCUSSION: PanIN refers to a small intraductal noninvasive lesion formed by metaplasia and proliferation of ductal epithelium. It is classified by dysplasia severity—PanIN 1 and 2 are low grade, and PanIN 3 is high grade. In orthotopic pancreas, PanIN 3 is known as carcinoma-in-situ. Conversely, PanIN 1 and 2 tumors grow slowly, might take up to 12 years to transition into PanIN 3 and even longer to change to PDA. These results can be extrapolated to pancreatic rest tissue due to similar mutations. Presently, asymptomatic pancreatic rest is monitored, while symptomatic cases—or those suspicious of malignancy on ultrasound—are resected using endoscopic techniques or surgical resection. There are no guidelines for endoscopic surveillance and therapy of these asymptomatic, premalignant and malignant gastric ectopic pancreatic rest lesions. In this case we highlight a very rare incidence of a low-grade premalignant lesion within gastric ectopic pancreatic rest removed by endoscopic resection. Further research is necessary to better define strategies for endoscopic surveillance and therapy of asymptomatic gastric ectopic pancreatic rest given the potentiality of these lesions to be premalignant and transform into malignant lesions that carry a poor prognosis.

Rare Case of Ectopic Pancreatic Cancer of the Jejunum

Ectopic pancreatic cancer is exceedingly rare. We present a case of ectopic pancreatic cancer of the jejunum. A 75-year-old female presented with severe acute abdominal pain and nausea for a few days. Abdominal CT showed a 3.7x4.7x4.2 cm mesenteric mass encasing the superior mesenteric artery (SMA). CT-guided biopsy demonstrated adenocarcinoma of unknown primary. She was initiated on fluorouracil and oxaliplatin, but with only transient response. Surveillance CT scans did not show any evidence of metastases. She then underwent exploratory laparotomy with resection of the mass and 3rd/4th portions of the duodenum and proximal jejunum, along with vascular reconstruction of the SMA. Final pathology results demonstrated adenocarcinoma in the jejunum arising from an ectopic pancreas with tumor invading the SMA. Ectopic pancreatic tissue is estimated to be present in the gastrointestinal tract in approximately 2-15% of the population. It is thought to develop during through metaplasia of the intestinal mucosa or congenitally. Rarely does ectopic pancreas degenerate into adenocarcinoma (0.7-1.8%). It also rarely invades the mesentery, in which case the jejunum is the most commonly found location. Masses invading the mesentery typically measure 3-5 cm. Heterotopic pancreas can lead to other uncommon complications such as ulceration of mucosa, gastrointestinal bleed, intestinal obstruction, and pancreatitis. The differential diagnosis also includes gastrointestinal stromal tumors, lymphomas, and carcinoid tumors. Vitiello et al. (2017) described 29 surgical cases of ectopic pancreas, with only 37.9% of patients symptomatic prior to surgery. Only 1 of these 29 cases demonstrated pancreatic cancer. Other therapies include chemotherapy, with less information available in the literature. However, Fukino et al. (2015) did report a case of gemcitabine being effective in treating duodenal ectopic pancreatic cancer. There was also one case by Ogawa et al. (2015) which utilized tegafur/gimeracil/oteracil potassium (S-1) and particle beam therapy yielding partial remission. Overall prognosis of jejunal ectopic pancreatic cancer is unclear, however, a literature review by Yamaoka et al. (2015) noted that survival for those with distant metastases appears to range from 5-9 months.

Pancreas herniation into the mediastinum: a case report

BackgroundPancreatic tissue found in the mediastinum (both true ectopic and herniated pancreas) is rare. It becomes even more challenging when there are complications associated with this entity.Case presentationWe report an unusual case of pancreatic herniation into the mediastinum in a 90-year-old Caucasian female. This patient initially presented with nausea and vomiting associated with abdominal pain. Serum lipase and amylase both were elevated. Computed tomography scan of the chest, abdomen and pelvis revealed a large hiatal hernia with pancreas herniation into the mediastinum, with superimposed acute pancreatitis likely due to gallstone. Because of its unusual location, the patient also developed acute mediastinitis. The patient was management conservatively and did well. On the day of discharge; she was tolerating a diet, had no pain or nausea and was back to her baseline health.ConclusionAcute pancreatitis can be managed conservatively even if it is in the mediastinum. Also, ectopic or herniated pancreatic tissue is extremely rare and leads to unique clinical presentations, along with diagnostic and therapeutic challenges. Clinicians should not only be vigilant to the presence of ectopic or herniated pancreatic tissue, but also be mindful of the resulting complications.

Clinical characteristics of Meckel diverticulum in children: A retrospective review of a 15-year single-center experience.

Meckel diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract in children. The aim of this study was to review and analyze clinical data on the diagnosis and management of Meckel diverticulum in pediatric patients. The records of 102 pediatric patients (<14 years old) who underwent surgery for Meckel diverticulum at our institute between 2001 and 2015 were reviewed. Clinical, imaging, laboratory, surgical, and pathological data were recorded. The series comprised 65 males and 37 females with a median age of 5.6 years. Lower gastrointestinal bleeding was the most frequently identified clinical manifestation of Meckel diverticulum, and this manifestation was observed in 41 patients. Intussusception secondary to Meckel diverticulum was identified in 32 patients. Twelve patients presented clinical features of peritonitis; of these patients, 8 had perforated Meckel diverticulum and 4 had Meckel diverticulitis. In 10 patients, Meckel diverticulum was incidentally diagnosed during other surgeries, including appendectomy and neonatal enterostomy. Seven patients were diagnosed with intestinal obstruction. Technetium-99m pertechnetate imaging offered high diagnostic yield. Open surgery was performed on 59 patients, while a laparoscopic approach was employed in 35 patients. The remaining 8 patients did not undergo resection of the Meckel diverticulum. Histology revealed ectopic gastric mucosa in 42 patients (44.7%), ectopic pancreatic tissue in 35 patients (37.2%), mucosa of the small intestine in 15 patients (16.0%), and both gastric and pancreatic ectopic tissue in 2 patients (2.1%). All patients recovered uneventfully except 2 patients in whom an intestinal adhesion obstruction was identified after discharge. Meckel diverticulum had various clinical manifestations in children. Technetium-99m pertechnetate imaging may be useful for diagnosing Meckel diverticulum. Surgical excision of the Meckel diverticulum may be safe and effective in symptomatic patients, and relatively better outcomes can be achieved using this approach.

Primary pancreatic-type acinar cell carcinoma of the jejunum with tumor thrombus extending into the mesenteric venous system: a case report and literature review

BackgroundAlthough ectopic pancreatic tissue is common in the upper gastrointestinal tract, the incidence of ectopic pancreatic tissue in the jejunum is low, and malignant transformation in ectopic pancreatic tissue is rare. Furthermore, pancreatic-type acinar cell carcinoma (ACC) developing in the jejunum and ACC accompanied by tumor thrombus are extremely rare.Case presentationA 78-year-old-woman presented with melena. Abdominal computed tomography images and endoscopic examination revealed a submucosal jejunal mass with tumor thrombus extending into a jejunal vein. The patient underwent a curative resection combined with a partial jejunectomy and partial pancreatectomy. Histopathological examination of the resected tissue showed tumor cells with a homogeneous acinar architecture identical to pancreatic-type ACC and tumor thrombus. Postoperatively, she was followed for 10 months and had no recurrence.ConclusionWe present an extremely rare case of pancreatic-type ACC in the jejunum with extensive tumor thrombus invading into the mesenteric venous system. This type of cancer has not been reported previously but should be considered in the differential diagnosis of a jejunal mass.

Clinical impact of duodenal pancreatic heterotopia \u2013 Is there a need for surgical treatment?

BackgroundPancreatic heterotopia (PH) is defined as ectopic pancreatic tissue outside the normal pancreas and its vasculature and duct system. Most frequently, PH is detected incidentally by histopathological examination. The aim of the present study was to analyze a large single-center series of duodenal PH with respect to the clinical presentation.MethodsA prospective pancreatic database was retrospectively analyzed for cases of PH of the duodenum. All pancreatic and duodenal resections performed between January 2000 and October 2015 were included and screened for histopathologically proven duodenal PH. PH was classified according to Heinrich’s classification (Type I acini, ducts, and islet cells; Type II acini and ducts; Type III only ducts).ResultsA total of 1274 pancreatic and duodenal resections were performed within the study period, and 67 cases of PH (5.3%) were identified. The respective patients were predominantly male (72%) and either underwent pancreatoduodenectomy (n = 60); a limited pancreas resection with partial duodenal resection (n = 4); distal pancreatectomy with partial duodenal resection (n = 1); total pancreatectomy (n = 1); or enucleation (n = 1). Whereas 65 patients (83.5%) were asymptomatic, 11 patients (18.4%) presented with symptoms related to PH (most frequently with abdominal pain [72%] and duodenal obstruction [55%]). Of those, seven patients (63.6%) had chronic pancreatitis in the heterotopic pancreas. The risk of malignant transformation into adenocarcinoma was 2.9%.ConclusionsPH is found in approximately 5% of pancreatic or duodenal resections and is generally asymptomatic. Chronic pancreatitis is not uncommon in heterotopic pancreatic tissue, and even there is a risk of malignant transformation. PH should be considered for the differential diagnosis of duodenal lesions and surgery should be considered, especially in symptomatic cases.

Natural Orifice–Assisted Laparoscopic Meckel Diverticulectomy Incidentally Found During Para-Aortic Mass Resection

Study ObjectiveTo show a surgical video in which an incidentally found Meckel diverticulum was resected with a natural orifice–assisted laparoscopic approach during para-aortic resection of a retroperitoneal schwannoma. DesignCase report (Canadian Task Force classification III). SettingTertiary referral center in New Haven, Connecticut. InterventionsThis is a step-by-step illustration for resection of a retroperitoneal para-aortic schwannoma and of an incidentally found Meckel diverticulum. The patient was a 39-year-old white woman diagnosed with stage IV choriocarcinoma with metastasis to the lungs and left para-aortic area. She received chemotherapy in the form of etoposide, methotrexate, actinomycin-D, cyclophosphamide, oncovine (EMA-CO) and had an excellent clinical response with resolution of all metastatic disease except for the para-aortic mass. Therefore, she was taken to the operating room for laparoscopic resection of the persistent left para-aortic mass. After placement of four 5-mm abdominal ports, the pelvis and abdomen were explored and revealed an incidental Meckel diverticulum as well as the 5 cm left para-aortic mass. The peritoneum overlying the para-aortic mass was incised and the retroperitoneum explored. Given the proximity to the mass, left ureterolysis was performed. The retroperitoneal attachments were resected, and the left para-aortic mass was removed without any complications. At this point attention was turned to the Meckel diverticulum. In order not to extend the abdominal incisions, a posterior colpotomy was performed in the cul-de-sac equidistant from the uterosacral ligaments. Endo-GIA (Covidien, New Haven CT) was introduced through the 10-mm port site at the posterior colpotomy. Meckel diverticulum was resected without narrowing the lumen of the distal ileum. The specimen was removed in a contained manner through posterior colpotomy. Measurements and Main ResultsThe procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 0. Pathology revealed a retroperitoneal schwannoma with negative margins and benign Meckel diverticulum without ectopic gastric or pancreatic tissue. The patient has been disease-free since the completion of surgery. ConclusionLaparoscopic resection of the retroperitoneal schwannoma and Meckel diverticulum were successfully performed in this patient with history of stage IV choriocarcinoma. To our knowledge, this is the first report describing a natural orifice–assisted laparoscopic approach for resection of Meckel diverticulum. Natural orifice–assisted laparoscopy should be considered when the surgeon needs to remove a large specimen and/or to introduce >5-mm diameter instruments into the peritoneal cavity without having to extend the abdominal incisions.

A Tumor Localized in the Portal Vein

Question: A 56-year-old man underwent annual abdominal ultrasonography (US) as a medical checkup and a mass was found in his portal vein. Further examination was required and he was admitted to our hospital. He had no significant chief complaints, family history, or past medical history. On physical examination, no significant findings were revealed. Laboratory data were as follows: aspartate aminotransferase of 57 IU/L, alanine aminotransferase of 42 IU/L, lactate dehydrogenase of 302 IU/L, and γ-glutamyltransferase of 248 IU/L. Tumor markers were as follows: carcinoembryonic antigen of 4.7 ng/mL carbohydrate antigen 19-9 of 0.9 U/mL, alpha-fetoprotein of 8.6 U/mL, DUPAN-2 of 155 U/mL, neuron-specific enolase of 17.74 ng/mL, and protein induced by vitamin K absence-2 of 18 mAU/mL. Serologic tests for hepatitis B virus and hepatitis C virus were negative. Abdominal US demonstrated a mass occupying the portal vein near the head of the pancreas (Figure A). Doppler examination demonstrated no blood flow in the portal vein. Early phase-enhanced computed tomography (CT) showed a homogenously enhanced mass occupying the portal vein and it elongated to secondary branches of the right intrahepatic portal vein and the superior mesenteric vein (Figure B). On CT and endoscopic US (EUS) examinations, there were no other detectable lesions suggesting primary tumors in the pancreas, liver or other organs. Positron emission tomography (PET) CT disclosed high enhancement in portal vein identical to the mass lesion (Figure C). How do you diagnose the tumor? What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. To make a histologic diagnosis, we performed endoscopic ultrasound fine needle aspiration (Figure D). Microscopically, the tumor showed an alveolar growth pattern and cells were eosinophilic and some of them were amphophilic (Figure E). Immunohistochemical staining for both bcl-10 (Figure F) and trypsin (Figure G) was positive in the tumor. These microscopic features were consistent with acinar cell carcinoma of the pancreas. Because the tumor was invaded into secondary branches of both the right and left intrahepatic veins and the superior mesenteric vein, the tumor was considered to be unresectable. We started treating the tumor with chemotherapy. Acinar cell carcinoma is a rare malignant epithelial neoplasm and represents 1% to 2% of all exocrine pancreatic neoplasms.1Sun Y. Wasserman P.G. Acinar cell carcinoma arising in the stomach: a case report with literature review.Hum Pathol. 2004; 35: 263-265Crossref PubMed Scopus (41) Google Scholar We herein described an extremely rare case of pancreatic acinar cell carcinoma localized in the portal vein without any detectable primary lesions in the pancreas or other organs. In our patient, all the imaging studies including US, CT, PET-CT, and EUS could not detect any tumors in the pancreas. There are few case reports on pancreatic acinar cell carcinoma arising from non-pancreatic tissues, including the stomach,1Sun Y. Wasserman P.G. Acinar cell carcinoma arising in the stomach: a case report with literature review.Hum Pathol. 2004; 35: 263-265Crossref PubMed Scopus (41) Google Scholar the ampulla of Vater,2Kawakami H. Kuwatani M. Onodera M. et al.Primary acinar cell carcinoma of the ampulla of Vater.J Gastroenterol. 2007; 42: 694-697Crossref PubMed Scopus (10) Google Scholar and the jejunum.3Makhlouf H.R. Almeida J.L. Sobin L.H. Carcinoma in jejunal pancreatic heterotopia.Arch Pathol Lab Med. 1999; 123: 707-711Crossref PubMed Google Scholar In these cases, tumors were considered to arise from ectopic pancreatic tissue, because these tissues are derived from endoderm. However, in our patient, it is developmentally unlikely that acinar cell carcinoma arise from ectopic pancreatic tissue in the portal vein that is derived from mesoderm. Intraductal growth into the portal vein is also a rare feature for pancreatic acinar cell carcinoma. A few cases with portal tumor thrombus of acinar cell carcinoma have been reported. However, all of these cases had primary lesions in the pancreas and the tumor invaded directly to the portal vein. In conclusion, even though extremely rare, pancreatic acinar cell carcinoma should be included in the differential diagnosis of a tumor localized in the portal vein.

異所性膵組織を伴った臍ポリープの 2 例

異所性膵組織を伴った臍ポリープの 2 例

Ektopično tkivo pankreasa u želucu - prikaz slučaja

Introduction: Ectopic pancreas is a rare developmental anomaly. It is a presence of pancreatic tissue without anatomic or vascular continuity with the normally developed pancreas. The most common heterotopic site is the stomach commonly involving antrum and prepyloric region on the greater curvature or posterior wall. Ectopic pancreas is diagnosed by endoscopic ultrasound, gastroscopy and biopsy, CT scan and MRI of the abdomen, a definitive diagnosis is verified by histopathological examination. Treatment is surgical. Case report: A 56-year-old woman presented with epigastric pain, nausea and fatigue. Esophagogastroduodenoscopy showed submucosal mass in the prepyloric region, biopsy was performed. Histopathological findings described normal gastric mucosa. Endoscopic ultrasonography and CT of the abdomen showed submucosal tumor, 18 mm in diameter, located in the prepyloric region. Surgical treatment was indicated. Gastrotomy with total extraction of tumor was performed. Histopathology findings showed ectopic pancreatic tissue in the submucosal and muscular layer of the stomach. Postoperatively patient fully recovered, and in the 2 year follow-up did not develop any symptoms related to gastrointestinal tract. Conclusion: Although presentation of ectopic pancreatic tissue in stomach is a very rare condition, it should be considered during gastroitestinal diagnostic in patients with nonspecific gastrointestinal symptomatology. In most of cases, for this patients, surgery is curative and definitive solution.

Ectopic pancreatic tissue in a Gallbladder

Ectopic pancreatic tissue in a Gallbladder

An Uncommon Lesion of the Duodenum

Brunner's gland cystadenomas are rare benign lesion of the duodenum and encompass a spectrum of fluid-filled to semi-solid duodenal wall cysts. We present a case of a 66-year-old male who presented for the evaluation of early satiety and dyspepsia. A 77-year-old male presented for the evaluation of a 3-month history of early satiety. The patient denied abdominal pain, weight loss, nausea, vomiting, and signs of gastrointestinal blood loss. Laboratory evaluation revealed a normal complete blood count and complete metabolic panel. An esophagogastroduodenoscopy (EGD) was performed which revealed a 2.0 x 1.4 cm submucosal cystic lesion located between the first and second portions of the duodenum. Biopsies were taken from the lesion using a tunnel technique, which resulted in the expression of a clear fluid from the cystic lesion. The lesion then subsequently flattening out. Biopsy results revealed normal overlying duodenal mucosa with hyperplastic Brunner's glands, consistent with Brunner's glands cystadenoma. Brunner's glands cystadenomas are a rare benign lesion of the duodenum that have a hallmark appearance of a submucosal lesion that will rupture when biopsied and then subsequently flatten out. Differential diagnosis of submucosal lesions in the duodenum, include leiomyoma, gastrointestinal stromal tumor (GIST), ectopic pancreatic tissue, neuroendocrine tumors, and granular cell tumors. This case served as a reminded of an uncommon lesion of the duodenum that may not be familiar to gastroenterologists because of their rarity.Figure 1Figure 2

Unexpected Ectopic Pancreatic tissue during laparoscopic bariatric surgery. Case report and literature review

Unexpected Ectopic Pancreatic tissue during laparoscopic bariatric surgery. Case report and literature review

Diagnostics of chronic small intestinal obstruction in patient with ectopic pancreas in the Meckel's diverticulum (case report)

Aim of the case report presentation. To draw attention of general practitioners to the rare case of intestinal obstruction - intussusception of Meckel's diverticulum in small intestinal lumen. Key points. The present case is characterized by development of chronic small-intestinal obstruction due to repeating intussusception of Meckel's diverticulum in the small intestinal lumen. Episodes of intussusception manifested clinically by attacks of severe right iliac pain that made patient to take «embryonic posture». Deep palpation revealed «spastic bowel» sign in the area of intussusception. A specific type of intussusception was detected by transabdominal ultrasound: thickening and «lamination of intestinal wall» due to «diverticulum interposition» into the lumen of ileum and «overlaying» of wall layers. The evacuation delay at the small intestine was followed by dilation of overlying loops of the small intestine containing bulky liquid content; pendular movement of liquid observed at ultrasonography with visible «air-fluid levels» at plain radiograph. The patient at the same time had frequent liquid stool that indicated presence of incomplete obstruction. Surgical intervention for intussusception and resection of diverticulum-containing portion of the small intestine resulted in improvement of the patient state, relief of pain attacks and signs of intestinal obstruction. Histological examination of resected specimen revealed the presence of ectopic pancreatic tissue in the Meckel's diverticulum wall. Conclusion. Carrying out differential diagnosis in colicky abdominal pain should encompass existence of Meckel's diverticulum with recurrent small intestinal intussusception that can result in chronic intestinal obstruction. In diverticulum wall ectopic pancreas can be detected. Key words: ileus, Meckel's diverticulum, ectopic pancreas.

Surgical Treatment and Morphological Aspects of Duodenal Dystrophy

Aim. To investigate the pathogenesis of cystic inflammatory transformation of duodenal wall in patients with chronic pancreatitis (CP), described as a “duodenal dystrophy” (DD), and to improve clinical efficiency of surgical treatment. Material and Methods. 532 patients with CP were examined for the period 2004–2016. Eighty two (15.4%) patients with DD were retrospectively included over 12 years. The diagnosis of DD was established by transabdominal ultrasound, CT, MRI and endosonography. Initially, all patients were treated conservatively. 74 patients required surgical treatment subsequently after conservative treatment with a median duration of 2 years. 34 patients underwent pancreaticoduodenectomy (PD), 21 patients underwent duodenal resection, 15 – duodenum-preserving pancreatic head resection of (DPPHR). 4 patients underwent palliative operations. CP and DD were verified by histological study of surgical specimens. Not operated patients (8) are under observation. Long-term results of surgical treatment were evaluated in 47 patients with a median follow-up 49.9 months. Results. Histological examination resulted that in 69.9% DD was related with groove pancreatitis, with ectopic pancreatic tissue – in 30.1%. DD was associated with CP in 92.6% of cases. Clinical presentation of DD was not related with etiology and showed typical symptoms of CP: abdominal pain occurred in 98.8% of patients, body weight loss – 61.7%, duodenal obstruction – 35.8%, biliary hypertension – 34.6%. The overall morbidity was 35.6%. Overall postoperative mortality was 1.37% (1 patient). 66% of patients had no clinical symptoms postoperatively, a significant improvement – 32%, no effect – 2%. Conclusion. The most cases DD is related with groove pancreatitis, less frequently – with ectopic pancreatic tissue in the duodenal wall. Typically DD occurs in patients with CP. Treatment of patients with CP and DD should be started with conservative therapy. Surgery is indicated for persistent abdominal pain and presence of CP complications. Procedures of choice are PD and DPPHR.

CYSTIC DEGENERATION OF THE DUODENUM ASSOCIATED WITH CHRONIC PANCREATITIS

Inflammatory cystic lesion of the descending part of the duodenum, mainly in the field of small duodenal papilla in chronic pancreatitis (CP) is described as “duodenal dystrophy” (DD). The pathogenesis of this condition has not been studied and treatment strategy is not defined. Purpose. Investigation of cystic inflammatory transformation of duodenal wall pathogenesis in patients with CP, described as a DD, and evaluate the clinical ef ficiency of surgical treatment. Material and methods . Eighty two patients with DD were retrospectively included over 12 years. The diagnosis of DD was established by transabdominal ultrasound, CT, MRI and endosonography. Initially, all patients were treated conservatively. 74 patients required surgical treatment subsequently after conservative treatment with a median duration of 2 years. 34 patients underwent pancreaticoduodenectomy (PD), 21 patients underwent duodenum resection, 15 – duodenum preserving pancreatic head resection of (DPPHR). 4 patients underwent palliative operations. Diagnosis of CP and DD was verified by histological study of surgical specimens. Not operated patients (8) are under observation. Long-term results of surgical treatment were evaluated in 47 patients with a median follow-up was 49.9 months. Results . Histological examination resulted that in 69.9% of DD was related with groove pancreatitis, with ectopic pancreatic tissue – in 30.1%. DD was associated with CP in 92.6% of cases. Clinical presentation of DD was not related with etiology and showed typical symptoms of CP: abdominal pain occurred in 98.8% of patients, body weight loss – 61.7%, duodenal obstruction – 35.8%, biliary hypertension – 34.1%. The overall morbidity was 35.1%. Overall postoperative mortality was 1.37% (1 patient). 66% of patients had no clinical symptoms postoperatively, a significant improvement – 32%, no effect – 2%. Conclusion. The most cases of DD is related with groove pancreatitis, less – with ectopic pancreatic tissue in the duodenal wall. Typically DD occurs in patients with CP. Treatment of patients with CP and DD should be started with conservative therapy. Surgery is indicated for persistent abdominal pain and presence of CP complications. Procedures of choice are PD and DPPHR.

Diagnosis and treatment of duodenal dystrophy in patients with chronic pancreatitis

to define optimal treatment of duodenal dystrophy in patients with chronic pancreatitis. 515 patients with chronic pancreatitis have been treated for the period 2004-2015 in A.V.Vishnevsky Institute of Surgery. Duodenal dystrophy (DD) was diagnosed in 79 (15.3%) of them. The diagnosis was confirmed by sonography, CT, MRI and endosonography. 5 patients are under observation without surgery. 74 patients were operated after previous medical therapy during 39 months on the average. Pancreatoduodenectomy was performed in 36 patients. Organ-sparing interventions were applied in 34 cases including different duodenal resections in 20 patients and pancreatic head resections in different modifications in 14 cases. 4 patients underwent palliative surgery. Chronic pancreatitis and DD were verified by morphological analysis of specimens. Long-term results were estimated in 47 patients. Median follow-up was 49.9 months. X-ray diagnostics showed that DD was combined with chronic pancreatitis in 87.3% of cases while morphological analysis revealed 93.8%. Clinical signs of DD were caused by striated pancreatitis in 69.6% and ectopic pancreatic tissue in 30.4%. Clinical manifestations of DD did not depend on its cause and were presented by symptoms of chronic pancreatitis. Postoperative complications occurred in 25 (34.7%) patients. There were 33.5% of complications after pancreatoduodenectomy and 70% after duodenal resection. 1 patient died. Overall mortality was 1,3%. In long-term period complete regression of symptoms was observed in 66% of cases, significant improvement - in 32%, absence of the effect - in 2%. Medical therapy should be preferred for patients with DD and chronic pancreatitis. Surgery is indicated in case of persistent pain, complicated course of chronic pancreatitis and duodenal obstruction. Pancreatoduodenectomy and pancreatic head resection are preferred.

Ectopic Intrathoracic Hepatic Tissue and Accessory Lung Lobe Aplasia in a Dog

A 6 yr old male Yorkshire terrier was presented for an ~6 yr history of progressive cough and dyspnea. Thoracic radiographs revealed a 6 cm diameter mass within the right caudal thorax. Thoracic ultrasound identified an intrathoracic mass ultrasonographically consistent with liver tissue and a chronic diaphragmatic hernia was suspected. Exploratory laparotomy was performed, but no evidence of a diaphragmatic hernia was identified. Thoracic exploration identified abnormal lung parenchyma. The accessory lung lobe was removed using a stapling devise near its base. The consolidated mass had the gross appearance of liver and was histologically identified as ectopic hepatic tissue. Ectopic hepatic tissue, unlike ectopic splenic and pancreatic tissue, is rare and generally has a subdiaphragmatic distribution. This solitary case report demonstrates that ectopic intrathoracic hepatic tissue should be considered a differential diagnosis for a caudal mediastinal mass.

Clinical picture: multiple sites of ectopic pancreatic tissue.

A case is presented with multiple sites of ectopic pancreatic tissue in the gastro-intestinal tract. The sites were found in the stomach and duodenum, one site of ectopic pancreatic tissue presented with necrotizing pancreatitis. Ectopic pancreatic tissue can be defined as all pancreatic tissue, with no anatomical or vascular continuity with the orthotopic pancreas. The ectopic tissue most likely originates from the spreading of cells, during the allocation of structures derived from the foregut in the embryonic phase. Over ninety percent of ectopic tissue presents in the upper gastrointestinal tract, although other locations have been described. To date this is the first case-report about a patient with multiple localizations of ectopic pancreatic tissue.

Robot-Assisted Resection of a Pyloric Pancreatic Rest with Peroral Endoscopic Removal and Reconstruction by Partial Gastroduodenostomy

Background: Gastric pancreatic rests consist of ectopic pancreatic tissue within the stomach wall and exhibit a typical endoscopic appearance. They are frequently asymptomatic, but can cause pain, erosions, and depending on their location, gastric outlet obstruction. Symptomatic pancreatic rests should be resected surgically. Objective: We report the first robot-assisted resection of a pyloric pancreatic rest with endoscopic removal of the tumor through the pharynx and subsequent reconstruction of the gastric outflow tract by partial gastroduodenostomy. Case: A 10-year-old girl presented with several months of worsening abdominal pain and nonbilious emesis. An upper gastrointestinal endoscopy showed a large pancreatic rest adjacent to and obstructing the pylorus, confirmed by endoscopic ultrasound. The patient was scheduled for robot-assisted resection of the tumor. Intraoperatively, resection of the mass with part of the pylorus was performed. To avoid augmenting one of the robotic trocar sites for removal of the tumor, the mass was pushed into the stomach and retrieved endoscopically through the esophagus and pharynx. The pylorus was reconstructed robotically by transverse gastroduodenostomy using interrupted sutures in two layers. The operative time was 320 minutes. Results: The patient tolerated the procedure well, advanced on her diet without difficulties, and discharged home on postoperative day 3. Histopathology confirmed the diagnosis. She remained asymptomatic, and an upper gastrointestinal contrast study 3 months later showed normal passage of contrast from the stomach into the duodenum. She remains asymptomatic at 8 months follow-up. Conclusions: Symptomatic pyloric pancreatic rests require careful excision with precise reconstruction of the gastric outflow tract, and therefore lend themselves to a robot-assisted approach. Endoscopic removal through the mouth as a natural orifice allows for removal without augmenting one of the trocar sites and thereby minimizes visible scars. If careful resection and reconstruction are achieved, the outcome is excellent. No competing financial interests exist. Runtime of video: 4 mins 50 secs This video was presented at the International Pediatric Endosurgery Group's 23rd Annual Congress, July 2014, in Edinburgh, Scotland.