Pancreaticoduodenal Research Articles

A Multi-Institutional Safety and Feasibility Study Exploring the Use of Hydrogel to Create Spatial Separation between the Pancreas and Duodenum in Patients with Pancreatic Cancer

IntroductionThe administration of dose-escalated radiation for pancreatic adenocarcinoma remains challenging due to the proximity of dose-limiting stomach and bowel, particularly the duodenum for pancreatic head tumors. We explore whether endoscopic injection of a temporary, absorbable hydrogel into the pancreatico-duodenal (PD) groove is safe and feasible for the purpose of increasing spatial separation between pancreatic head tumors and the duodenum. MethodsSix patients with localized pancreatic adenocarcinoma underwent endoscopic injection of hydrogel into the PD groove. Safety was assessed based on the incidence of procedure-related adverse events resulting in a delay of radiation therapy initiation. Feasibility was defined as the ability to create spatial separation between the pancreas and duodenum, as assessed on simulation CT. ResultsAll six patients were able to undergo endoscopic injection of hydrogel into the PD groove. No device-related events were experienced at any point in follow-up. Presence of hydrogel in the PD groove was apparent on simulation CT in all six patients. Mean space created by the hydrogel was 7.7 mm +/- 2.4 mm. In three patients who underwent Whipple resection, presence of hydrogel in the PD groove was pathologically confirmed with no evidence of damage to the duodenum. ConclusionsEndoscopic injection of hydrogel into the PD groove is safe and feasible. Characterization of the dosimetric benefit that this technique may offer in the setting of dose-escalated radiation should also be pursued, as should the ability of such dosimetric benefit to translate into clinically improved tumor control.

Using Hydrogel to Create Spatial Separation between the Pancreas and Duodenum in Patients with Pancreatic Cancer: A Multi-Institutional Safety and Feasibility Study

<h3>Purpose/Objective(s)</h3> Emerging data supports the use of dose-escalated radiation therapy (RT) for pancreatic adenocarcinoma (PDAC), but administration of ablative dosing with good target coverage is often limited by the proximity of the duodenum. Endoscopic injection of a hydrogel spacer into the pancreatico-duodenal (PD) groove may increase spatial separation between pancreatic tumors and the duodenum, thereby better enabling ablative RT, and previous preclinical data have supported this approach. Herein, we report results from a multi-institutional study exploring the safety and feasibility of hydrogel injections into the PD groove in patients with PDAC. <h3>Materials/Methods</h3> Patients undergoing RT for localized PDAC centered in the pancreatic head were eligible across three institutions. Patients with evidence of duodenal invasion were excluded. Hydrogel was injected in 1 mL increments along the PD groove under endoscopic ultrasound (EUS) guidance. The primary endpoint was safety, defined by procedure-related adverse events (AEs) that resulted in a delay in RT initiation, and feasibility, defined as evidence of hydrogel in the PD groove on simulation CT. Additional endpoints included the amount of space created between the pancreas and the duodenum and hydrogel visibility on cone-beam CT (CBCT). Pathologic evidence of hydrogel-related duodenal injury was also assessed in patients who underwent Whipple resection. <h3>Results</h3> Six patients were enrolled with a median age of 70 years (range 60-80 years). Disease stage at presentation included borderline resectable (n=4) and locally advanced (n=2) disease, with a median tumor diameter of 3.2 cm (range 2.3-3.5 cm). All patients underwent at least four months of systemic therapy before RT. Radiation modality included five-fraction stereotactic body RT (n=5, median dose 33 Gy, range 33-40 Gy) and intensity modulated RT (n=1, 58.8 Gy). All patients successfully underwent EUS-guided hydrogel injection into the PD groove with a median injected volume of 3.4 cc (range 2.5-10 cc) over a median of 4 injections per procedure (range 3-12). No patients experienced a procedure-related AE that delayed RT initiation. Additionally, over a median follow-up of 14.8 months (range 5.5-18.9 months), no device-related AEs occurred. On post-injection simulation CT, hydrogel was present in the PD groove in all six patients. Median space creation at the level of the hydrogel was 7.7 +/- 2.4 mm. Hydrogel was visible on CBCT in all patients. No evidence of pathologic duodenal damage was present in three patients who underwent resection. <h3>Conclusion</h3> Endoscopic injection of hydrogel into the PD groove appears safe and feasible. Continued efforts are needed to optimize the ability to inject larger volumes of hydrogel along the PD interface and to develop methods that can predict specific locations along the PD groove that would benefit most from hydrogel placement.

Anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades in the human pancreas: a cadaveric study.

The purpose of this work was to evaluate the arteries supplying the pancreaticoduodenal (PD) complex. The study was conducted on 15 fresh enbloc pancreatic specimens by latex injection method which enabled the visualization of the peripancreatic arteries and their minute branches. The gastroduodenal (GDA), anterior superior pancreaticoduodenal (ASPD), and anterior inferior pancreaticoduodenal (AIPD) artery was found in all the cases, whereas the posterior superior pancreaticoduodenal (PSPD) and posterior inferior pancreaticoduodenal (PIPD) artery was present in 93.34% cases. The ASPD artery originated from GDA in all the cases. Two types of variations were observed in the origin of PSPD artery and four types each in the origin of AIPD and PIPD artery. Anatomical and numerical variations were observed in both anterior and posterior arches, posterior arch being absent in 20% cases. In the present study, an attempt was made to systematically describe the individual arterial configurations of the PD complex. The information provided here has important implications for preoperative planning of technically challenging surgeries and interventions around the pancreatic head.

Common hepatic artery embolization is an unnecessary procedure before DP CAR. Experience of 40 surgeries without arterial reconstructions

Background: Distal pancreatectomy with celiac artery (CA) resection (DPCAR) is an option for borderline resectable pancreatic body cancer. It is believed that the reduction of arterial blood supply after DPCAR may cause severe liver ischemia. Decision to embolize preoperatively or reconstruct common hepatic artery (СHA) during DPCAR is under discussion. Aim: To assess postDPCAR events: Primary: liver arterial supply, arterial blood flow intensity (BFI) through the pancreaticoduodenal (PDA), gastroduodenal (GDA) and proper hepatic (PHA) arteries. Secondary: morbidity, 90-days mortality,pancreatic fistulas B/C, OS, DFS. Patients and methods: Arterial anatomy, diameters of CHA, PDA, GDA and PHA were registered before and after 40 DP CARs by CT. IOUS (40) and ICG–gastroscopy (10) were ischemia assessment tools. Preoperative CHA embolization was never used. Results: Among 52 CA resections 12 procedures were excluded because of GDA involvement and necessity for total duodenopancreatectomy/arterial reconstruction. In all 40 residuary cases of DPCAR arterial flow in liver parenchyma was preserved and there were no CHA reconstructions. GDA, PDA and PHA BFI increased in 0,71-90 times after DPCAR, BFI in PHA didn’t change significantly after surgery. Gastric ischemia was revealed in 4 and liver ischemia in 0 cases. R0 -resection was achieved in 36 (90%) cases. Chemotherapy for PDAC(31) was neoadjuvant (11) and adjuvant (16). Morbidity-57,5%, B/Cfistulas-8 (20%), mortality-3 (7,5%), OS-30 months, DFS-16 months, Three and 5-year survival were 83%,43% and 41%, Actual 5-y OS -19.5%. Conclusion: As CHA reconstruction, so as its preoperative occlusion are unnecessary procedures for DPCAR. IOUS is a reliable method for liver ischemia assessment during DPCAR, which is less frequent event than gastric ischemia.

Pancreatico duodenal trauma in children: Two-year experience at a regional referral center and tertiary care teaching hospital

Background:Pancreatico-Duodenal injuries, though rare, pose a mighty challenge to the surgeon in both diagnosis and treatment. More so in children, where the patho-physiologic threshold is low. Added to this is the absence of any strong guidelines to guide and ensure standardised care in these children for best outcome.Materials and Methods:The trauma patients' records in the emergency department, operation theatre, inpatient departmrnt, outpatient department (OPD) for the period of December 2016 to December 2018 in the institution were retrospectively reviewed, to find out the cases of pancreaticoduodenal trauma proven radiologically, biochemically and/or on laparotomy. Those cases then studied with respect to diagnosis, treatment and short term outcome.Results:Of the 256 cases of abdominal trauma, suspected pancreatico duodenal (PD) trauma were in nine but on laparotomy actually eight of them had PD trauma. All were blunt abdominal traumas sustained in road traffic accidents. Of these one was combined pancreatico duodenal while three were pure pancreatic and four were pure duodenal. One had associated superior mesenteric vein trauma. All were managed operatively. There were no mortality, one fourth had major complications. Mean hospital stay was 22.25 days. Follow up period varied from six to 32 months.Conclusion:Though PD traumas are rare but are potentially very morbid and may prove fatal. Proactive individualized management, multidisciplinary approach and good perioperative support can yield good results.

Pancreaticoduodenal arterial arcades: Their dominance and variations—their potential clinical relevance

The complex arterial system makes pancreatic interventions technically challenging for surgeons, and interventional radiologists. The arterial variants may alter tumor resecability, and cause complications in arterial embolization. International data on pancreatic blood supply are variable; therefore, we aimed to determine the frequency of variants of pancreaticoduodenal (PD) arterial arcades. Arteries of human abdominal organ complexes (50) were injected with resin mixture, and then corroded. CT scans and three-dimensional reconstructions were made; diameters of arcades were measured. Two PD arcades were found in 58%, three arcades in 30%, one arcade in three cases, four arcade in one specimen, and five arcades in two cases. In the casts with two arches the average diameter was 1.472 ± 0.432 mm on the anterior and 1.383 ± 0.343 mm on the posterior arch. Assessing the dominance of the PD arcades, the anterior arch proved to be dominant in 52% of the cases, and in 35% the posterior one by the criterion of 25% cross-section difference. It is advised to analyze the variations and dominance on a CT/MR-angiography before local chemotherapy. Furthermore, to reveal the arterial variations, a preoperative CT/MR-angiography would provide faster recuperation and better postoperative life quality. Clin. Anat. 31:544-550, 2018. © 2018 Wiley Periodicals, Inc.

Long-term outcomes in patients with multiple endocrine neoplasia type 1 and pancreaticoduodenal neuroendocrine tumours.

In patients with multiple endocrine neoplasia type 1 (MEN-1), pancreaticoduodenal (PD) neuroendocrine tumours (NETs) are associated with early mortality, yet the best treatment strategy remains uncertain. To assess patient important outcomes (mortality and metastasis) of PD-NETs and predictors of outcomes in patients with MEN-1. Retrospective cohort of patients with MEN-1 who attended the Mayo Clinic, Rochester, MN from 1997 to 2014. We identified 287 patients with MEN-1; 199 (69%) patients had 217 PD-NETs. Among those with a PD-NETs, 129 (65%) had surgery of which 90 (70%) had their primary surgery performed at Mayo Clinic. The median postoperative follow-up was 8 years during which 13 (14%) patients died. The mean (±standard deviation) age of death was 51 (±9) years. Tumour size, metastasis at surgery or tumour type were not predictive of mortality, but for every year older at surgery, the odds of metastasis increased by 6%. Surgery was not performed in 70 (35%) patients. Among those who were observed/medically managed without known metastatic disease, mean tumour growth was 0·02 cm/year (range, -0·13-0·4 cm/year). Four patients (7%) died at a median age of 77 (range, 51-89) years. PD-NETs are common in patients with MEN-1 and are associated with early mortality even after surgical intervention. Active surveillance is a viable option in nonaggressive PD-NETs, although definitive factors identifying such patients are lacking. Therefore, counselling regarding risks and benefits of current treatment options remains integral to the care of patients with MEN-1.

Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis?

True aneurysms of the gastroduodenal (GDA) and pancreaticoduodenal (PDA) arteries have been attributed to increased collateral flow due to tandem celiac artery stenosis or occlusion. Although GDA and PDA aneurysm exclusion is recommended because of the high reported risk of rupture, it remains uncertain whether simultaneous celiac artery reconstruction is necessary to preserve end-organ flow. We conducted a retrospective analysis of consecutive patients admitted from 1996 to 2015 with true aneurysms of the GDA or PDA. Twenty patients with true aneurysms of the PDA (n= 16) or GDA (n= 4) were identified. Mean age was 61.5 years (range 35 to 85 years) and 11 (55%) were women. Nine (45%) presented with rupture, 8 (40%) presented with pain, and 3 (15%) were asymptomatic. All 9 patients who presented with rupture had contained retroperitoneal hematomas, and none experienced rebleeding. Fifteen (75%) patients had an associated celiac artery >60% stenosis or occlusion, and 2 (10%) had both celiac and superior mesenteric artery stenoses. Thirteen (65%) patients underwent successful endovascular coiling, only 1 of which had a prophylactic celiac artery bypass. Three (15%) patients underwent open aneurysm exclusion and celiac bypass, and 4 (20%) others were observed. There were no aneurysm-related deaths in this series, and none of the patients who underwent coiling without celiac revascularization had hepatic ischemia or other mesenteric morbidity develop during a median follow-up of 6 months (maximum 200 months). Gastroduodenal artery and PDA aneurysms present most commonly with pain or bleeding, and all should be considered for repair, regardless of size. Aneurysm exclusion is safely and effectively achieved with endovascular coiling. Although associated celiac artery stenosis is found in the majority of cases, celiac revascularization might not be necessary.

Groove pancreatitis: Imaging features and management

The aim of this retrospective study was to highlight the imaging findings of groove pancreatitis (GP) as well as its management. Patients and methods16 patients diagnosed to have GP were enrolled in this work. The included patients had complete records of the thorough clinical examination and laboratory workup. All patients had been examined by multi-phase contrast enhanced MDCT tailored for pancreatic imaging. Six of these patients were additionally examined by MRI including MRCP., ResultsMDCT Multiple detector computed tomography of the 16 patients revealedthe following: (1) a hypodense sheet in the pancreaticoduodenal (PD) groove seen in 12 patients with mild enhancement in the delayed phase seen in 6 of the them; (2) Duodenal wall thickening was seen in 10 patients while (3) associated cysts within the duodenal wall or in PD groove were seen in 6 patients; (4) and pancreatic head enlargement in 8 patients. MRI of Six patients revealedthe following: (1) a T1 hypointense and T2 iso to hyperintense sheet at the PD groove in 4 patients with delayed enhancement in 3 of them; (2) Duodenal wall thickening with T2 high signal was seen in 6 patients while associated cysts within the duodenal wall were seen in 4 patients; (3) Pancreatic head enlargement seen in 4 patients; The MRCP of these patients showed dilated CBD with distal tapering and a distance separating its end from the duodenal wall. ConclusionGP is a disease that should be considered in the list of differential diagnosis of masses implicating the pancreatic head and medial duodenal wall. Imaging findings that are suggestive of GP include chronic inflammatory changes with fibrosis in the PD groove with or without implication of the nearby head of the pancreas, duodenal medial mural thickening with luminal stenosis and cysts at the PD groove or within the duodenal wall. Vascular invasion is a sign against diagnosis of GP.

SS8. Contemporary Outcomes of Intact (iVAA) and Ruptured (rVAA) Visceral Artery Aneurysm Repair

To review the outcomes of open and endovascular intervention for intact visceral artery aneurysm (iVAA) and ruptured VAA (rVAA). Retrospective review of treated VAA at one institution from 2003 to 2013. We identified 261patients with VAA; of these 155 were repaired (69 ruptured, 86 intact; Table). Pseudoaneurysms were more common in rVAA (80%) vs iVAA (35%; P < .001). rVAA were smaller than iVAA (20.5 vs 27.5 mm; P = .018) at repair, and their most common presentation was abdominal pain; 18% were hemodynamically unstable. Endovascular intervention was the initial treatment for 70% (78% for rVAA, 63% for iVAA). Perioperative complication rate was higher for rVAA (19% vs iVAA 4%; P = .003), as well as 30-day (12% vs 0% iVAA; P = .001), 1-year (26% vs 4% iVAA; P < .001), and 3-year (30% vs 7% iVAA; P < .001) mortality. Lower 30-day mortality was noted with endovascular repair for rVAA (7% vs 28% open; P = .06). Predictors of mortality for rVAA included age (HR, 1.098; P = .006) whereas endovascular repair was protective (HR, 0.231; P = .035). Mean follow up was 26 months, and Kaplan-Meier estimates of survival were higher for iVAA at 3 years (88% vs 62% iVAA, P = .045). The 30-day reintervention rate was higher for rVAA (9% vs 1% iVAA; P = .045), but was similar between open and endovascular repair (8.5% vs 15%, P = NS). rVAAs have significant mortality. Open or endovascular interventions are equally durable, but endovascular interventions for rVAA result in lower morbidity and mortality. Aggressive treatment of pseudoaneurysms is electively recommended at diagnosis, regardless of size.TableRuptured VAA (N = 69)No. (%)Gender (Male)43 (62.3)Age (mean)±SD5S.8 ± 15Smoking16 (23.2)VAA type (pseudoaneurysm)55 (79.7)Mean size (mm) (range)20.5 (3.5-75)Splenic19 (27.5)Celiac6 (8.7)SMA8 (11.6)Hepatic16 (23.2)Renal1 (1.5)Pancreaticoduodenal (PDA)18 (26.1)Comorbidities DM8 (11.6) CRI6 (8.7) ESRD1 (1.4) Hypertension41 (59.4) Hyperlipidemia13 (18.8) CAD4 (5.9) COPD7 (10.1) CVA5 (7.2) Pancreatitis29 (42) Open table in a new tab

Infective aneurysm of the inferior pancreaticoduodenal artery

Pancreaticoduodenal (PD) artery aneurysms account for less than 2% of all splanchnic aneurysms. A mycotic aetiology is extremely uncommon. Two weeks following an episode of sepsis related to a prostatic biopsy, a 59-year-old man presented with abdominal pain and anaemia. Ultrasonography and computed tomography revealed an inferior PD artery pseudoaneurysm with an associated mesenteric root haematoma. This was treated successfully by transcatheter embolisation. Infective pseudoaneurysms of the PD artery are rare but can be associated with rupture into the gastrointestinal tract or retroperitoneum. Transcatheter embolisation remains the most effective therapy as it is associated with low morbidity and mortality rates and recurrence is very unlikely provided the aneurysm is completely excluded from the circulation.

Surgical management of peripancreatic arterial aneurysms

Peripancreatic artery aneurysms—gastroduodenal (GDA) and pancreaticoduodenal (PDA)—are highly unusual. We report 4 such aneurysms and have collated reports of true peripancreatic artery aneurysms based on an extensive review of the English literature. From this review, patient characteristics, clinical behavior, outcome and management strategies are assessed.

Long-term studies of pancreas allotransplantation in experimental diabetes mellitus.

Pancreaticoduodenal (PD) allografts (Brown Norway-alloxan-diabetic rats, n = 190) were treated with cyclosporin A (Cy-A) 10 mg/kg/daily and compared with nondiabetics with Cy-A treatment (n = 55), diabetics (n = 50), and diabetics with Cy-A treatment (n = 45). Body weight, blood sugar, blood insulin, blood urea nitrogen (BUN), and creatinine were monitored periodically; there were marked elevations of BUN and creatinine levels, indicating probably nephrotoxicity of Cy-A at this dosage. Some islet cell atrophy in the PD allografts was noted at the conclusion of the study. With respect to the immunosuppressive effect of Cy-A in alloxan diabetic rats, Brown Norway PD transplants into Lewis rats were successful and free of rejection for as long as 15 months post-transplantation. The body weight of these PD transplanted rats, however, never approached values representative of the nondiabetic rats. In our experience, the PD allograft model is acceptable in the clinical situation, particularly in children if the microsurgical technique is mastered and if the Cy-A regimen is used in combination with other immunosuppressant(s).

Effects of pancreaticoduodenal allografts on diabetic testicular lesions in the rat

AbstractAbnormal testicular histology is common in untreated diabetic animals and men. Reversal of testicular lesions with return of function and fertility are seen in controlled diabetes. We investigated the effects of pancreaticoduodenal (PD) allografts on testicular lesions of alloxan‐induced diabetic rats. For periods of l to 15 months, 190 diabetic Lewis rats were allowed to remain diabetic before receiving PD transplants and Cyclosporin A (CsA); 190 other rats were divided into 4 control groups: normal rats with and without CsA, and diabetic rats with and without CsA. Following transplantation, transplanted rats and corresponding controls were sacrificed at 3‐month intervals. Testicles were morphometrically examined. CsA did not affect rat testicular histology. All successfully transplanted rats (n = 97) had complete reversal of hyperglycemia. In the first 6 months following transplantation, the testicular lesions appear to worsen; thereafter, the testicular sizes, tubular densities, and percentages of germinal tissue converge toward nondiabetic levels. This convergence was more marked in the later transplantation groups (≥ 9 months of diabetes before receiving transplantation) than in the earlier groups (&lt;9 months). Overall, these results suggest that PD transplantation may partially reverse testicular lesions. Although pancreas transplantation may initially worsen diabetic testicular lesions, after 6 months, improvement of the lesions can be expected. Thus, an important result from this study relating to the clinical laboratory is that good control of the blood glucose in diabetics causes reversal of diabetic testicular lesions with return of function and fertility. In addition, Cyclosporin levels should be monitored in clinical laboratories in transplant patients to prevent toxic injury to the kidney and liver. However, Cyclosporin did not damage the testis in our study.

Pancreaticoduodenal transplantation in the rat.

SUMMARY A technique for pancreaticoduodenal (PD) transplantation in the rat is presented. The rejection reaction in pancreatic grafts in inbred strains of rats is described. The major complication, acute hemorrhagic pancreatitis, can be partially prevented by carefully ligating tributaries in the vicinity of the pancreas, reducing the is chemic time, perfusing with cold saline, and using a no-touch technique.

PANCREATICO–DUODENAL RESECTION, WITH REPORT OF A CASE

PANCREATICO–DUODENAL RESECTION, WITH REPORT OF A CASE