Pancreatic Head Research Articles

Effect of warm and cold ischemia on pancreaticoduodenectomy specimen following robotic pancreaticoduodenectomy

BackgroundThe adoption of robotic pancreaticoduodenectomy (PD) has increased in recent years for the treatment of pancreatic head tumors and periampullary lesions. Some potential benefits seem to be demonstrated; however, obtaining specimens through this method can potentially compromise the diagnosis depending on the timing of the specimen retrieval, and the impact of longer perioperative time on ischemia and autolysis of the surgical specimen has not been analyzed. The aim of this study is to evaluate the histological changes associated with timing of specimen retrieval during robotic PD.MethodsA review of histopathology files was performed for all pancreatic specimens collected at our hospital from January 2022 to March 2024. Both warm ischemia time (WIT) and cold ischemia time (CIT) were collected. Histological features related to ischemic damage were evaluated in normal duodenal and pancreatic parenchyma as well as pancreatic tumor, and were graded as: absent, mild, moderate and severe. Univariate and multivariate analyses were performed to determine which variables were associated with moderate and severe ischemic changes.ResultsSixty surgical specimens were analyzed: 20 open PD, 17 robotic PD with cold ischemia, and 23 robotic PD. Median total WIT was 182 min (open PD 57 min vs. RPD 190 min vs. RPD-CI 198 min; p < 0.001). Median CIT was 760 min (740–835) in samples stored at 4ºC. Univariate analysis showed that longer intraoperative time, male gender and cold ischemia were associated with pancreatic tissue ischemic changes. In multivariate analysis, cold ischemia was the only independent factor associated with normal pancreatic tissue and tumor tissue moderate and severe ischemic changes.ConclusionsProlonged ischemia time, especially in the case of cold storage, has a strong effect on the degradation of normal and tumor tissue without affecting pathological evaluation. Operative teams should aim to optimize both the duration and efficiency of the surgical procedure, ensuring minimal ischemic time. Simultaneously, pathology departments must be equipped to process pancreatic specimens promptly, with protocols in place to minimize the time between resection and analysis.

The short-term outcomes of laparoscopic enucleation of pancreatic tumors with exposing the Wirsung duct.

It is widely believed that the prerequisite for safely performing enucleation is that the distance between the tumor and the main pancreatic duct (MPD) is at least 2-3mm. However, enucleating a deep pancreatic tumor adjacent to the MPD remains challenging, particularly when exposure or repair of the MPD is necessary. This study reported our initial experience with this procedure and demonstrated the feasibility and safety of the MPD exposure or repair. Patients who underwent laparoscopic enucleation (LapEN) with exposing the MPD from January 2017 to August 2023 were collected and analyzed in this retrospective cohort study. Data from procedures of laparoscopic middle pancreatectomy (LMP) and LapEN for superficial tumors were collected for comparative analyses. A total of 26 patients were enrolled, 27 tumors were enucleated. Tumor located in the pancreatic head and neck (n = 20), and the body (n = 7). The mean tumor size, operating time, and blood loss were 2.3cm, 163min, and 63ml, respectively. MPD injuries occurred in 8 cases due to the need for complete tumor resection, which were repaired or reconstructed using 6-0 PDS-II with or not inserting a plastic stent. 10 cases (38.5%) developed surgical-related complications, seven (26.9%) were classified as Clavien-Dindo grade I, and three (11.5%) were Clavien-Dindo grade IIIa. Biochemical leakage occurred in 16 cases (61.5%), clinically relevant pancreatic fistula (CR-POPF) occurred in 10 cases (38.5%). Two patients (7.7%) experiencedpost-pancreatectomy hemorrhage. Further analyses indicated LapEN with MPD exposure had a longer operating time and higher incidence of CR-POPF compared to LapEN for superficial tumors, but a shorter operating time and less blood loss compared to LMP (P < 0.05). Laparoscopic enucleation with exposing the MPD is feasible and safe with the support of precise preoperative assessments, meticulous intraoperative dissection, well familiarity with the anatomy of the MPD, and excellent surgical skills.

Insulinoma with suspected mutant somatostatin receptor expression according to histological examination

Key Clinical MessageThis case highlights the possibility of an insulinoma expressing an aberrant form of SSTRs resulting in a discrepancy between the preoperative octreotide assessment and postoperative SSTR expression.AbstractInsulinoma is a pancreatic disease that causes hyperinsulinemic hypoglycemia. The first‐line treatment is surgery; however, somatostatin derivatives are administered in cases where surgery is not a viable option and to prevent preoperative hypoglycemia. Here, we report a case in which preoperative examination indicated a potential tumor with low somatostatin receptor 2 (SSTR2) and SSTR5 expression, whereas postoperative pathological examination indicated strong SSTR expression. We report the case of a 69‐year‐old Japanese female who experienced hypoglycemia‐like symptoms for a decade such as sweating, fatigue, hunger, and confusion with an increase in episode frequency per year. Dynamic computed tomography revealed a 13‐mm diameter nodule and aberrant blood flow in the pancreatic tail. Subsequently, the patient was diagnosed with pancreatic insulinoma. A preoperative octreotide test did not relieve hypoglycemia, and no uptake of 111indium‐pentetreotide was observed, suggesting an insulinoma with low SSTR expression. However, postoperative histological studies suggested that the intracellular domain of SSTRs were highly expressed, while the extracellular domain may be mutated. We present a rare case of insulinoma expressing an aberrant form of SSTRs resulting in a discrepancy between the preoperative octreotide assessment and postoperative SSTR expression.

A new technique of primary retroperitoneal approach for minimally invasive surgical treatment of cecal colon cancer with d3 lymph node dissection.

In patients with high BMI and cardiopulmonary disease, the specificity of the laparoscopic approach may be an obstacle to the use of minimally invasive surgery. The primary retroperitoneal approach may overcome some of the unfavorable aspects of laparoscopic surgery and provide new possibilities for minimally invasive treatments. In this report, we present right colon resection using a primary retroperitoneal approach, in a patient with adhesions caused by previous surgical interventions. A single-port single-access system is placed in the right lateral region of the abdomen. Dissection was performed between Toldt's fascia and Gerota's fascia. Medial to the head of the pancreas, the posterior layer of the mesentery was dissected along the course of the superior mesenteric artery and the dissection continues caudally. The roots of the ileocolic vessels were identified, clipped and cut at their origin while the dissection of the D3 lymph node was carried out along the trunk of Gillot up to the origin of the middle colic artery. The right colonic resection with D3 lymph node dissection was performed with primary retroperitoneal approach. The duration of the surgery was 240min, with blood loss up to 100ml. The incidence of pain syndrome in the early postoperative period was low and the hospital stay lasted 7days. The primary retroperitoneal approach appears to be safe for the treatment of cecal colon cancer. The anatomical structures are accessible and easy to visualize, allowing for safe resection of the right colon with extended D3 lymph node dissection.

After 30 Years of Remission, Recurrence With Renal Cell Carcinoma Metastasis Mimicking Pancreatic Neuroendocrine Tumor on 18F-FDG and 68Ga-DOTATATE PET/CT.

A 75-year-old man with a previous history of left nephrectomy for clear cell renal cell carcinoma in remission was underwent 68Ga-DOTATATE PET/CT imaging for evaluation of pancreatic body lesion. It showed a mass with intense 68Ga-DOTATATE uptake in the pancreatic corpus. During the follow-up of the patient who did not want to undergo surgery, 18F-FDG PET/CT scan was performed due to the increase in the size of the mass, and mild FDG uptake was detected in the pancreatic corpus lesion, and histopathological examination was confirmed as renal cell carcinoma metastasis.

Hydatid cyst in the tail of the pancreas: a rare case report

Hydatid cysts, caused by Echinococcus granulosus, are rare but significant when found in the pancreas, particularly in endemic regions. This case report discusses a 32-year-old female with a pancreatic tail cyst presenting with epigastric pain and intermittent fever. Diagnostic imaging, contrast enhanced computed tomography (CECT) and magnetic resonance cholangiopancreatography (MRCP), and serological tests were inconclusive, making preoperative diagnosis challenging. Differential diagnoses included pancreatic pseudocysts, benign neoplasms, abscesses, and other cystic lesions. The patient underwent surgical exploration, where a hydatid cyst was identified and treated with cyst removal, partial pericystectomy, and marsupialization. Postoperative management included albendazole therapy. Pancreatic hydatid cysts, though rare, should be considered in differential diagnoses for pancreatic cystic lesions, especially in endemic areas. Accurate diagnosis typically requires a combination of imaging, serology, and histopathological examination, with surgery often necessary for definitive diagnosis and treatment.

Three main portal veins: A very rare case of portal vein anomaly

Portal vein (PV) anomalies are rare during embryonic development, with very few cases of duplicated PVs reported. This case reveals a new PV trunk anomaly, where computed tomography venography imaging shows three portal veins. The superior mesenteric vein and inferior mesenteric vein join to form a trunk that divides into two branches: One entering the liver (PV1) and the other ascending to join the splenic vein. The splenic vein then divides into two branches in the neck of the pancreas (PV2 and PV3), both entering the liver. The three PVs vary in thickness and all enter the liver through the first hepatic portal. Understanding the normal structure and anatomy of the PV is important for successful surgical planning. This case involves three main trunks of the PV, which is an extremely rare type of PV duplication anomaly. Reporting this case aims to enhance the awareness and understanding of PV duplication anomalies among clinicians and radiologists.

Pancreaticogastrostomy: A Safe and Effective Reconstruction Method After Pancreaticoduodenectomy: A Short Observational Study

Background: Pancreaticoduodenal resection is usually performed in patients with a localised small carcinoma in the head of the pancreas, at the lower end of the common bile duct or at the ampulla and occasionally for chronic pancreatitis.The mortality following pancreaticoduodenal resection has fallen and is now below 5% 1-6 .However, leakage from the anastomosis between pancreas and the jejunum has been and remains, one of the most worrying complications of the operation. The data from papers published in the last 8 years show that the incidence of pancreatic leak is 14% and the mortality of this complication 24%3,4,6-16 .Pancreaticogastrostomy is a potentially safer alternative to pancreaticojejunostomy in the reconstruction following Whipple's operation. Aim: The aim of the study was to observe pancreaticogastrostomy is a potentially safer alternative to pancreaticojejunostomy after pancreaticoduodenectomy. Methods: This prospective observational study was conducted at the Department of Surgery in Shaheed Suhrawardy Medical College Hospital, for One year (August 2021 to July 2022). Patients with a localised small carcinoma in the head of the pancreas, at the lower end of the common bile duct or at the ampulla, and occasionally for chronic pancreatitis admitted in the department of surgery were approached for inclusion in the study. Total 41 patients were selected according to inclusion and exclusion criteria. Informed written consent was taken from each patient. All patients underwent pancreaticogastrostomy. Detail clinical and demographic history was taken along with thorough physical examination relevant investigations. All patients were evaluated preoperatively and post operatively at discharge, 1 month and 3 months. Outcome was assessed post operatively. Collected data were checked and analysed in SPSS 23. Results: Two patients died within 30 days of the operation (mortality 4.9%), one from perioperative haemorrhage and another from septicaemia due to a biliary infection, which may have resulted from preoperative transhepatic biliary drainage. Both operations were carried out for carcinoma of the head of the pancreas. One patient developed a biliary leak which closed in 6 days. A postoperative pancreatic leak occurred in one patient with carcinoma of the ampulla; the fistula closed after 5 mdays, and did not delay his discharge from hospital. This patient remains well 36 months after operation, although he has now developed mild diabetes.One other patient developed diabetes mellitus postoperatively. This woman had evidence of obstructive pancreatitis at operation. She died 6 months later of recurrent carcinoma of the head of the pancreas. One patient with chronic pancreatitis has uncontrolled steatorrhoea, with up to four bowel movements a day. Four other patients take regular pancreatic supplements together with H2 receptor antagonists in order to maintain normal defaecation. There has been no case of stomal ulceration. None of the patients were lost to follow-up. The median survival for patients operated on for carcinoma of the head of the pancreas was 13 months, and for patients with carcinoma of the bile duct, 14 months. Median survival of patients with ampullary carcinoma was 38 months. Conclusion: Seventy two percent of patients had good outcome after Pancreaticogastrostomy(PG). Significant relief in symptoms of pain were noted after PG. Further larger study is recommended to validate this findings. J Shaheed Suhrawardy Med Coll 2023; 15(1): 66-72

An innovative surgical approach for solid pseudopapillary neoplasm with duodenal invasion in a pediatric patient: a case report

BackgroundPediatric pancreatic tumors, especially with duodenal invasion, are exceptionally rare and a strategy for their treatment has not been established. A pancreaticoduodenectomy is often the desired treatment, but may be over-invasive for solid pseudopapillary neoplasm (SPN). This study reports an innovative surgical approach for SPN with duodenal invasion using pancreatic enucleation and endoscopically guided partial duodenectomy.Case presentationAn 11-year-old girl complained of malaise and presented with severe anemia; imaging revealed a tumor of undetermined origin, involving the pancreatic head and descending duodenum. Intraoperative findings showed tumor adherence to the pancreatic head and endoscopy revealed invasion of the duodenum. The tumor was enucleated from the pancreatic head, and partial duodenectomy was performed under endoscopically guided direct visualization. Pathology confirmed SPN with duodenal invasion, and no residual tumor. Although a Grade B pancreatic fistula occurred postoperatively, it was managed conservatively. At the 15-month follow-up, no signs of tumor recurrence, duodenal stenosis, or pancreatic dysfunction were evident.ConclusionsGiven the good prognosis of SPN, we believe that enucleation from the pancreatic head combined with an endoscopically guided partial duodenectomy could be a useful and less invasive alternative to pancreaticoduodenectomy for cases with duodenal invasion.

Disseminated Cryptococcus over pancreas, lung, and brain: a case report

BackgroundCryptococcus is an opportunistic infection acquired through inhalation from the environment, primarily affecting individuals with compromised immune systems. It typically leads to pneumonia upon passing through lung tissue. The infection can disseminate to various organs via the bloodstream, resulting in meningitis or encephalitis in the central nervous system. Disseminated Cryptococcus has been reported to involve the skin, liver, eyes, lymph nodes, bone marrow, spleen, kidneys, and intestines, significantly increasing morbidity and mortality. However, pancreatic involvement in Cryptococcus is relatively rare, and a few case reports have highlighted severe organ damage and high mortality rates.Case presentationIn this case report, we present the case of a 36-year-old Asian man who presented with a 2-week history of headaches and blurred vision in his right eye. Brain magnetic resonance imaging revealed multiple brain masses, along with a mass in the lower left lung field and a tumor in the pancreatic tail, as detected by chest computed tomography. Endoscopic ultrasound-guided fine needle biopsy and computed tomography-guided lung biopsy confirmed the diagnosis of disseminated cryptococcal infection involving the pancreas, lung, and brain. The patient’s clinical condition improved following antifungal therapy. Additionally, we identified anti-granulocyte–macrophage colony-stimulating factor antibody as a risk factor for disseminated cryptococcal infection in this patient.ConclusionDisseminated cryptococcosis can be a potentially lethal condition, as highlighted by previous literature. However, early diagnosis using contrast-enhanced harmonic endoscopic ultrasound and endoscopic ultrasound-guided biopsies, as well as prompt treatment as demonstrated in our case, can improve outcomes and prevent mortality.

An aggressive gastric CIC-DUX4 sarcoma surgically resected with multivisceral organs: a case report

BackgroundCapicua transcriptional repressor-double homeobox 4 sarcoma (CDS) is a rare and aggressive malignant soft tissue tumor that typically arises within the soft tissues. We report an exceptionally rare case of a gastric CDS successfully resected despite its extensive invasion into surrounding organs.Case presentationA 48-year-old male presented with a progressively enlarging abdominal mass. Upper gastrointestinal endoscopy revealed a large ulcerative tumor on the posterior gastric wall. Biopsy results initially suggested a neuroendocrine cell carcinoma. Contrast-enhanced computed tomography showed a 20 cm tumor protruding from the posterior stomach wall, directly invading the pancreas and colon. We performed a multivisceral resection (stomach, pancreatic tail, spleen, and transverse colon) achieving an R0 resection. Pathological examination of the permanent specimen revealed small round cells with high nuclear-to-cytoplasmic ratios. Immunohistochemical staining confirmed the diagnosis of CDS. The patient recovered well and was discharged on postoperative day 33.ConclusionsThis case report describes the first detailed account of a surgically resected aggressive CDS originating from the stomach.

Study of variations in the origin and branching of the human dorsal pancreatic artery

In surgical practice, the human pancreas is conventionally divided into two major anatomical and surgical segments: the right (cephalo-cervical) and the left (corpore-caudal). Both of these segments are abundantly supplied with blood. The artery-first approach is widely used in pancreatic resections to avoid venous stasis and achieve reduced blood loss. The dorsal pancreatic artery participates in the blood supply of both segments with its branches, which makes its anatomical study relevant and promising for clinical medicine. The aim was to describe the main branches of the dorsal pancreatic artery and to determine the frequency of their occurrence in the studied cases. Materials and Methods. The work was performed on archival fixed material (n = 60) of duodenum-pancreas-spleen organ complexes with extra-organ vessels taken from the collection of the Department of Anatomy, RyazSMU. All organ complexes belonged to mature age people without pronounced pathology of the organs of the investigated area. The division by sex was not performed. Results. The dorsal pancreatic artery was identified in all cases studied. Most often (n = 40; 67%) it originated from the branches of the ventral trunk, less often (n = 18; 30%) it was a branch of the superior mesenteric artery and in two cases (3%). Despite the place of origin, its trunk diameter averaged 1.8 mm (min 1.6; max 2.0). The branches of this artery were most often directed towards the gland body (85% of cases), less often - towards the head (15%). Conclusion. The dorsal pancreatic artery is the main artery feeding the body and tail of the human pancreas. In the present study, its branches were more frequently recorded towards the body of the gland, despite the origin of the vessel. Despite the accumulated anatomical and clinical knowledge about the peculiarities of the origin and branching of the human dorsal pancreatic artery, the understanding of the principles of the direction of its branches remains open to researchers.

Comparative evaluation of hepatosteatosis in patients with type 2 diabetes mellitus using non-contrast abdominal CT and laboratory findings

Aim: This study aims to underscore the significance of employing multiple parameters from non-contrast abdominal CT scans for the assessment of hepatosteatosis in patients with Type 2 Diabetes Mellitus. Methods: Non-enhanced Computed Tomography of the diabetic subjects were analyzed. Control subjects were selected from non-diabetic patients who had undergone abdominal tomography within the same period. The craniocaudal length of the liver and liver, spleen, pancreas densities, and epicardial adipose tissue were measured. Additionally, patient demographics and laboratory values were retrospectively obtained. Results: The craniocaudal length of the liver was significantly greater in the diabetes mellitus group compared to the control group (168.3 ± 17.2 mm vs 152.3 ± 14.8 mm, p &lt; 0.001). Hepatosteatosis was observed in 22 individuals with diabetes mellitus, whereas only one participant in the control group had this condition (p &lt; 0.001). The diabetes mellitus group exhibited significantly lower median liver density (p &lt; 0.001), liver-spleen density ratio (p = 0.004), pancreatic head density (p = 0.001), and pancreatic body density (p = 0.013). Additionally, the average thickness of epicardial adipose tissue was markedly higher in the diabetes mellitus group compared to the control group (8.1 ± 1.9 mm vs 4.9 ± 1.1 mm, p &lt; 0.001). Conclusions: These data indicate an association between hepatosteatosis and increased epicardial adipose tissue thickness, liver and pancreatic densities in individuals with diabetes mellitus. These findings suggest that non-contrast abdominal CT findings such as epicardial adipose tissue thickness and relevant laboratory tests may aid in evaluating metabolic disorders and fat accumulation in diabetic patients.

Increased Proportion of the Squamous Cell Carcinoma Components Is Associated with Aggressive Behavior and a Worse Prognosis in Resected Pancreatic Adenosquamous Carcinoma.

Pancreatic adenosquamous carcinoma (PASC) is a subtype of pancreatic cancer with a poorer prognosis than pancreatic ductal carcinoma (PDAC). The pathogenesis of this histological subtype has not been fully explained due to its rarity. Of the 245 patients who underwent pancreatic resection for pancreatic cancer, six (2.3%) were diagnosed with PASC. They were retrospectively allocated to Group A (≥ 50% adenocarcinoma components) or Group S (≥ 50% squamous cell carcinoma components). The six patients with PASC were all males between the ages of 63 and 77years, with tumors of 12 to 52mm in diameter. Tumors were located in the pancreatic head (n = 2) and the pancreatic tail (n = 4). Relative to Group A, all three patients in Group S had larger tumors diameters, ≥ 40mm with invasion to other organs. Cancer-specific survival of Group S was worse than that of the PDAC group (median survival, 1.5years vs. 4.1years). All patients in Group A were alive at the end of follow-up. Recurrence-free survival of Group S was inferior to that of the PDAC group (median survival, 0.2years vs. 1.8years; Group A, not defined). Immunohistochemistry revealed the MIB-1 positivity rate in squamous cell carcinoma regions was 1.8 times higher than that in adenocarcinoma regions in the same specimens. In PASC patients, an increased proportion of squamous cell carcinoma components was associated with aggressive behavior and a worse prognosis. This was due to the high MIB-1 positivity rate of squamous cell carcinoma components.

Perioperative medication therapy for Muslim patients in Germany undergoing oncological surgery: a retrospective study

PurposeEngagement of healthcare professionals with patients from diverse cultural and religious backgrounds is crucial in our multicultural society, where miscommunication and errors in medical history taking can lead to incorrect treatment. In particular, Muslim patients may present unique considerations due to their specific cultural and religious beliefs, which can significantly impact treatment outcomes. This study focuses on perioperative medication therapy for patients undergoing upper and lower gastrointestinal tract and pancreatic tumor surgery, specifically examining whether Islamic beliefs were duly considered in medication selection compared to a matching patient cohort.Materials and methodsData from January 2004 to July 2023 were analyzed. Muslim patients were identified using the onomastic method and matched with non-Muslim patients at a 1:3 ratio based on age, gender, and procedure. Analysis included examination of subcutaneous, oral, and intravenous medications, with attention to ingredients and compatibility with Islamic principles.ResultsAmong 5272 patients, only 5 met the study’s inclusion criteria as Muslim patients, undergoing procedures such as anterior rectum resection, gastrectomy, and pancreatic head resection. Their religious affiliations were not documented in the admission records. According to the matched-pair analysis, consistent treatment was performed regardless of religious beliefs. All patients received subcutaneous medication, primarily enoxaparin, instead of fondaparinux, an Islam-compliant alternative. Intravenous heparin was used once for short period. Contrary to Islamic dietary restrictions and the availability of alternatives, capsules containing animal-derived gelatin and other non-compliant medications were administered orally.ConclusionThis study underscores the importance of acknowledging Muslim patients’ cultural and religious backgrounds in the perioperative setting, as failure to do so may lead healthcare professionals to overlook their potential alternative medication needs, which are essential for providing tailored medical care in modern societies. Integration of diversity-related topics into medical curricula is essential for better preparing physicians for clinical practice and ensuring patient-centered care.

Elevated Urinary Levels of Fungal and Environmental Toxins in Patients with Pancreatic Ductal Adenocarcinoma

BackgroundRisk factors for pancreatic ductal adenocarcinoma (PDAC) include tobacco/alcohol abuse, genetic predisposition, insulin resistance, and pancreatic cysts. Despite these well-established risk factors and the screening of high-risk individuals, some people still develop PDAC. This study aims to explore a potential risk factor for PDAC by investigating the association between fungal toxins (FT) and environmental toxins (ET) and the disease. We predicted that individuals with PDAC would have higher levels of these toxins compared to healthy controls. The rationale behind this hypothesis is that exposure to FT and ET might contribute to the development of PDAC by elevating cancer risk.MethodsA pilot retrospective cohort study was conducted at Moffitt Cancer Center from 2022 to 2023. This study compared FT and ET levels, demographic data, and PDAC features between subjects with PDAC and healthy controls.ResultsForty subjects were enrolled in the study, comprising 20 with pancreatic ductal adenocarcinoma (PDAC) and 20 healthy controls. Baseline demographics were similar between the two groups. Among the PDAC subjects, the most common tumor location was the head of the pancreas (55%); 30% had locally advanced disease, 45% were borderline resectable, and 10% had metastatic disease.Compared to the controls, subjects with PDAC had significantly higher levels of fungal toxins (FTs) including ochratoxin, gliotoxin, and citrinin (p < 0.05). Additionally, PDAC patients had significantly elevated levels of environmental toxins (ETs) such as methyl tert-butyl ether (MTBE), xylene, styrene, acrylonitrile, perchlorate, diphenyl phosphate, bromopropane, organophosphates, acrolein, tiglylglycine, and diethylphosphate (p < 0.05).ConclusionOur study demonstrates that subjects with PDAC, without other risk factors, have higher FT and ET levels than controls. Further studies are needed to evaluate whether ET and FT exposure can be clinically utilized as a risk factor for PDAC development.

Afferent loop syndrome following pancreatic head cancer surgery treated with metal stent placement using a short-type single-balloon enteroscope.

Afferent loop syndrome following pancreatic head cancer surgery treated with metal stent placement using a short-type single-balloon enteroscope.

Anatomical variants of the jejunal veins and their technical implications in pancreaticoduodenectomy: a systematic review and meta-analysis.

One of the most common causes of bleeding during pancreaticoduodenectomy (PD) is dissection of the pancreatic head from the superior mesenteric vein (SMV) and superior mesenteric artery (SMA). Knowledge of the anatomical variants of the veins draining the proximal jejunum may allow a better control of bleeding during detachment of the uncinate process and pancreatic head from the mesenteric pedicle and division of the mesopancreas. The aim of this systematic review and meta-analysis is to evaluate the anatomical variations of the first jejunal vein (FJV) and jejunal trunk (FJT). Fourteen studies (1,888 patients) were included. We performed a systematic review of the available Literature according to the PRISMA guidelines. The analysis has shown that the posterior course of the FJT and FJV represents the most frequent topographical location (PPE 79.6%) with the anterior jejunal trunk (JT) having a lower rate (PPE 20.4%). Few articles reported the variations with separate trunks for the first and second jejunal vein. A thorough preoperative radiological assessment of the anatomical variation of FJT and FJV may confer some advantage to establish the best therapeutic strategy and the best surgical approach in case of pancreatic head carcinoma, as it can allow a better estimate of the extent of the neoplasm and improve the accuracy of surgical dissection with potential for reduced bleeding.

Application of LEF-1 immunohistochemical staining in the diagnosis of solid pseudopapillary neoplasm of the pancreas

IntroductionSolid pseudopapillary neoplasm (SPN) is a tumor of young females with gain-of-function mutation in catenin beta 1 gene involved in Wnt signal transduction pathway. Beta-catenin immunohistochemistry (IHC) is used to diagnose SPN. Lymphoid enhancer-binding factor 1 (LEF-1) has been recognized in the transactivation of Wnt pathway. We aim to study LEF-1 IHC in SPN and other pancreatic tumors and compare it with beta-catenin IHC. MethodsWe retrieved cases of SPN, pancreatic neuroendocrine tumor (PanNET), serous cystadenoma (SCA), ductal adenocarcinoma (PDAC) and acinar cell carcinoma (ACC) from 2011 to 2023. Formalin-fixed, paraffin-embedded blocks with adequate tumor were cut and stained with beta-catenin (B-Catenin-1 clone) and LEF-1 (EP310 clone) IHC. Cases were reviewed by two pathologists independently. Nuclear staining with LEF-1 and beta-catenin was considered as positive. ResultsOur cohort consisted of 111 cases [SPN = 59 (42 resections, 11 FNA, 6 biopsies), PDAC = 24, PanNET = 22, SCA = 5, ACC = 1]. For SPN cases male to female ratio was1:8. Age ranged from 9 to 81 years (average: 32 years). Pancreatic tail was the most common location (47 %) followed by head (28 %), body (19 %) and neck (6 %). Tumor size ranged from 1.0 to 12.2 cm (average: 5 cm). Among the SPN cases 57/59 demonstrated strong nuclear LEF-1 staining. 2/49 cases were negative for LEF-1 (both pathologist in agreement). All SPN tumors demonstrated nuclear staining with beta-catenin. Among the non-SPN tumors, beta-catenin showed nuclear staining in 2/52 cases (2 PDAC). The remaining 50 cases were negative for nuclear beta-catenin and demonstrated variable staining pattern with interpretation variability between the two pathologists. The sensitivity and specificity for LEF-1 were 97 % and 100 %, respectively, while for beta-catenin, they were 100 % and 96 % respectively. ConclusionCrisp nuclear staining of LEF-1 without background staining makes diagnostic interpretation relatively easy and accurate compared to beta-catenin IHC. This is further helpful for small biopsy samples to help differentiate SPN from mimickers such as PanNET. None of the non-SPN cases displayed nuclear LEF-1 rendering it a valuable adjunct to beta-catenin in the diagnostic evaluation of SPN.

The efficacy of wrapping with polyglycolic acid mesh and fibrin glue in preventing clinically relevant pancreatic fistula after minimally invasive distal pancreatectomy (WRAP Study): study protocol for a multicenter randomized controlled trial in Japan

BackgroundPostoperative pancreatic fistula (POPF) continues to be the most common complication after distal pancreatectomy (DP). Recent advancements in surgical techniques have established minimally invasive distal pancreatectomy (MIDP) as the standard treatment for various conditions, including pancreatic cancer. However, MIDP has not demonstrated a clear advantage over open DP in terms of POPF rates, indicating the need for additional strategies to prevent POPF in MIDP. This trial (WRAP study) aims to evaluate the efficacy of wrapping the pancreatic stump with polyglycolic acid (PGA) mesh and fibrin glue in preventing clinically relevant (CR-) POPF following MIDP.MethodsThis multicenter, randomized controlled trial will include patients scheduled for laparoscopic or robotic DP for tumors in the pancreatic body and/or tail. Eligible participants will be centrally randomized into either the control group (Group A) or the intervention group (Group B), where the pancreatic stump will be reinforced by PGA mesh and fibrin glue. In both groups, pancreatic transection will be performed using a bioabsorbable reinforcement-attached stapler. A total of 172 patients will be enrolled across 14 high-volume centers in Japan. The primary endpoint is the incidence of CR-POPF (International Study Group of Pancreatic Surgery grade B/C).DiscussionThe WRAP study will determine whether the reinforcement of the pancreatic stump with PGA mesh and fibrin glue, a technique whose utility has been previously debated, could become the best practice in the era of MIDP, thereby enhancing its safety.Trial registrationThis trial was registered with the Japan Registry of Clinical Trials on June 15, 2024 (jRCTs032240120).