Pancreatic Head Tumor Research Articles

Role of biliary stent and neoadjuvant chemotherapy in the pancreatic tumor microbiome

BackgroundIntra-tumor microbiota have been implicated in pancreatic ductal adenocarcinoma (PDAC) development, treatment response and post-treatment survivorship. Moreover, therapeutic interventions targeting microbiota may improve the response to chemotherapy and immunotherapy, further emphasizing the critical need to understand the origins of and growth of bacteria within the pancreatic tumor microenvironment. Here, we studied the role of several clinical factors on the bacterial colonization of PDAC.ResultsWe obtained matched tumor and normal pancreatic tissue specimens from 27 patients who had undergone surgical resection for PDAC between 2011 and 2015 from the University of Minnesota Biological Materials Procurement Network (BioNet). We found that 26 (48%) out of 54 pancreatic tissue samples harbored detectable bacterial communities using real-time PCR targeting the 16S rRNA gene. Bacterial colonization was detected significantly more frequently in samples from patients who had pancreatic head tumors, underwent Whipple procedure, or had preoperative biliary stent placement. There was also a significantly greater relative abundance of microbiota from the family Enterobacteriaceae among samples from patients who underwent biliary stent placement or neoadjuvant treatment with a combination of Gemcitabine and Paclitaxel.ConclusionsThese findings suggest that biliary stent placement and neoadjuvant chemotherapy are associated with specific alterations that promote the infiltration and growth of intra-tumor bacteria in the setting of PDAC. Further studies exploring whether specific bacterial communities could contribute to increased chemoresistance will be essential for optimizing medical therapies in the future.

S1597 A Rare Presentation of Lemmel’s Syndrome as Acute Cholangitis With Acute Pancreatitis

Introduction: Duodenal diverticula are most commonly found in the second part of the duodenum adjacent to the ampulla of Vater. Periampullary diverticula (PAD) are extraluminal pseudo-diverticula lacking a mucosal layer. Although typically asymptomatic, they can rarely cause pancreaticobiliary obstruction. Obstructive jaundice can develop secondary to PAD without choledocholithiasis, a rare phenomenon called Lemmel’s Syndrome. We report a rare case of Lemmel’s syndrome presenting not only with acute cholangitis but also with concurrent pancreatitis, successfully treated with ERCP. Case Description/Methods: An 83-year-old female presented with upper abdominal pain, nausea, diarrhea, and rigors. She is s/p cholecystectomy and labs revealed AST 688 U/L, ALT 305 U/L, Alkaline Phosphatase 201 U/L, total bilirubin 3.4 mg/dL, lipase 968 U/L, and lactate 2.9 mmol/L. An abdominal CT scan showed severe dilation of the common bile duct of 2.1 cm with edematous appearance of the pancreatic head, findings of acute pancreatitis, and a large duodenal diverticulum adjacent to the pancreatic head (Fig 1). Her hospital course was complicated by gram negative bacteremia, concerning for acute cholangitis. MRCP confirmed marked dilation of the common bile duct extending to the Ampulla of Vater with a large periampullary diverticulum, without choledocholithiasis or mass lesions (Fig 2). The patient underwent ERCP which revealed a large duodenal diverticulum compressing the distal bile duct, treated with biliary sphincterotomy and stent placement (Fig 3-4). She showed gradual clinical improvement with this endoscopic approach and was discharged home with subsequent follow up for stent removal performed 6 weeks later. Discussion: Although common among duodenal diverticula, PAD are rarely symptomatic. The underlying pathogenesis remains unclear but is believed to be related to mechanical obstruction, inflammation, and fibrosis. Lemmel’s syndrome can be mistaken for pseudocysts, necrotic collections, periampullary tumors, and pancreatic head neoplasms. Physicians should have a high index of suspicion for Lemmel’s syndrome in patients with large symptomatic PAD, which although commonly presents as biliary obstruction causing acute cholangitis, can rarely also cause pancreatic obstruction leading to pancreatitis, as seen in our patient. Timely diagnosis and endoscopic treatment of Lemmel’s syndrome can be effective in the treatment of acute cholangitis and pancreatitis.Figure 1.: CT scan showing CBD dilation with large periampullary diverticulum.Figure 2.: MRI showing dilated CBD and PD with distal large periampullary diverticulum.Figure 3.: Endoscopic view of large periampullary diverticula with intradiverticular papilla seen on ERCP.Figure 4.: Fluoroscopic view of dilated CBD as a result of Lemmel’s syndrome.

S1555 Stage IV Tail of the Pancreas Tumor Presenting With Obstructive Jaundice Secondary to Liver Metastasis

Introduction: Pancreatic cancer is an aggressive disease with a poor prognosis. It is most commonly found in the head of the pancreas and 20-25% in the body and tail. The clinical manifestations vary based on the location and spread of the tumor. Case Description/Methods: Our patient is a 55-year-old male with a past medical history of hypertension and nicotine use disorder who presented with dull epigastric abdominal pain of 3-month duration. The review of systems was significant for anorexia, unintentional weight loss of 40 pounds, tea-colored urine, and acholic stool. He was vitally stable. Physical examination showed scleral icterus and a diffusely tender abdomen without peritoneal signs. Laboratory work showed elevated AST, ALT, alkaline phosphatase, total bilirubin, direct bilirubin, and lipase. A computerized tomography (CT) scan of the abdomen revealed a mass in the pancreatic tail, multiple heterogeneous hypodense hepatic masses, and basilar lung nodular opacities. An abdominal ultrasound (US) showed ascites, multiple hepatic masses, intrahepatic biliary dilatation, and a common bile duct of 7 mm. US-guided liver and pancreas biopsies were performed. Magnetic resonance cholangiopancreatography (MRCP) revealed a 3.5 cm mass in the tail of the pancreas, multiple hepatic masses that were compressing the common hepatic duct, and retroperitoneal lymphadenopathy (Figure 1). Histopathology studies confirmed stage IV pancreatic adenocarcinoma with metastasis to the liver, lung, and peritoneum. Given the patient's extensive metastatic disease, he was not a candidate for chemotherapy or surgical intervention. Hospice and palliative care were pursued. Discussion: Tumors of the body and tail of the pancreas have been associated with poor outcomes with a 0-25% 5-year survival rate even after surgical resection. Its late presentation prompts an increased risk of distant lymphatic and hematogenous dissemination when compared with pancreatic head neoplasms. Consequently, patients with tumors originating in the head of the pancreas often present early with symptomatic obstructive jaundice. Interestingly, our patient presented with obstructive jaundice, but it was caused by intrahepatic cholestasis secondary to liver metastasis compressing the common hepatic duct. This case highlights that even as obstructive jaundice is most frequently related to pancreatic head malignancies, pancreatic body/tail neoplasms may have this clinical presentation in the presence of liver metastasis.Figure 1.: MRCP of abdomen showing a mass in the tail of the pancreas (Black arrow) and multiple hepatic masses (White arrow).

Our Experience in Single Center Endoscopic Retrograde Cholangiopancreatography

Amaç: Endoskopik retrograd kolanjiopankreatografi (ERCP), safra yolu ve pankreasın benign ve malign patolojilerinin tanı ve tedavisinde etkin bir biçimde kullanılmaktadır. ERCP bilgi, beceri ve pratik gerektiren kompleks bir uygulamadır. Diğer endoskopik uygulamalardan farklı teknik ve ekipmanın kullanımı ve daha fazla komplikasyon görülmesiyle ayrılır. Bu çalışmadaki amacımız bir genel cerrahi ERCP ünitesinin 19 aylık deneyimini paylaşmaktır. Materyal ve metod: Bu çalışmada15 Mayıs 2019-31Aralık 2020 tarihleri arasında klinik, medikal ve radyolojik verilerde kolestaz, obstruktif kolanjit/pankreatit veya safra kaçağı tanısı konulan ve ERCP işlemi yapılan 513 hastanın verileri retrospektif olarak değerlendirmiştir. Bulgular: Çalışmaya alınan hastaların yaş dağılımı 18-109 arasında ve yaş ortalaması 58,54±20,16 idi. Cinsiyet dağılımı; 356 kadın (%69,4), 157 erkek (%30,6) şeklinde idi. En sık safra yolu tıkanıklığına bağlı kolestaz, tıkanma ikteri, akut pankreatit veya kolanjit tanıları konulmuştu. Bu hastaların 452 si koledok taşı, 15’i pankreas başı tümörü, 11’i koledok tümörü ve 10’u papilla tümörü idi.10 hasta Oddi Sfinkter Disfonksiyonu( ODS) nedeniyle işleme alındı. Safra yolu tıkanılığı ile gelen 499 hastanın 63’ü akut biliyer pankreatit, 38 i akut kolanjit tanılarıyla yatırılmıştı. İşlem süresi 20 dakikayla 90 dakika arasında değişti (ortalama işlem süresi 37 dk). Hastaların ERCP sonrası, 56’sında tedavi gerektirmeyen amilazemi, 24‘ünde ortalama 3 günlük medikal tedaviyle gerileyen pankreatit, 5’inde kan transfüzyonu gerektirmeyen ve adrenalin enjeksiyonu ve balon baskısıyla kontrol edilebilen kanama gelişti. Bir hastada taş ekstraksiyonu sırasında basket ve taş papillada sıkışmıştı. Operatif mortalite olmadı. Sonuç; Safra yollarındaki kaçaklar ve fistüller en iyi ERCP ile gösterilir ve endoskopik olarak tedavi edilir. Etkin olduğu kadar bünyesinde perforasyon, sepsis ve mortalite gibi çok ciddi komplikasyonları barındırdığından endoskopistin uygulamanın endikasyonunu doğru belirlemesi, potansiyel komplikasyonlarını bilmesi ve oluşan komplikasyonları erken bir şekilde tanıması ve tadavisini yönetmesi, komplikasyon yaratacak ve gereksiz uygulamalardan mumkun olduğunca kaçınması gerektiği kanaatindeyiz.

Deployable ultrasound applicators for endoluminal delivery of volumetric hyperthermia

Purpose To investigate the design of an endoluminal deployable ultrasound applicator for delivering volumetric hyperthermia to deep tissue sites as a possible adjunct to radiation and chemotherapy. Method This study considers an ultrasound applicator consisting of two tubular transducers situated at the end of a catheter assembly, encased within a distensible conical shaped balloon-based reflector that redirects acoustic energy distally into the tissue. The applicator assembly can be inserted endoluminally or laparoscopically in a compact form and expanded after delivery to the target site. Comprehensive acoustic and biothermal simulations and parametric studies were employed in generalized 3D and patient-specific pancreatic head and body tumor models to characterize the acoustic performance and evaluate heating capabilities of the applicator by investigating the device at a range of operating frequencies, tissue acoustic and thermal properties, transducer configurations, power modulation, applicator positioning, and by analyzing the resultant 40, 41, and 43 °C isothermal volumes and penetration depth of the heating volume. Intensity distributions and volumetric temperature contours were calculated to define moderate hyperthermia boundaries. Results Parametric studies demonstrated the frequency selection to control volume and depth of therapeutic heating from 62 to 22 cm3 and 4 to 2.6 cm as frequency ranges from 1 MHz to 4.7 MHz, respectively. Width of the heating profile tracks closely with the aperture. Water cooling within the reflector balloon was effective in controlling temperature to 37 °C maximum within the luminal wall. Patient-specific studies indicated that applicators with extended OD in the range of 3.6–6.2 cm with 0.5–1 cm long and 1 cm OD transducers can heat volumes of 1.1–7 cm3, 3–26 cm3, and 3.3–37.4 cm3 of pancreatic body and head tumors above 43, 41, and 40 °C, respectively. Conclusion In silico studies demonstrated the feasibility of combining endoluminal ultrasound with an integrated expandable balloon reflector for delivering volumetric hyperthermia in regions adjacent to body lumens and cavities.

Pancreatic angiosarcoma: A case report

Pancreatic cancer has a relative 5-year survival of less than 10%. The most common neoplasm of the pancreas is ductal adenocarcinoma, which comprises 85% of all malignant pancreatic tumours. Primary pancreatic sarcomas are extremely rare which account for less than 0.1% of all pancreatic malignancies and pancreatic angiosarcomas attribute to 1% of all tissue sarcomas. Sarcomas of the pancreas are more aggressive and have a dismal prognosis. A 69-year-old lady presented with obstructive jaundice, abdominal discomfort and associated constitutional symptoms. She was investigated and found to have obstructive jaundice with normal tumor marker assays. An endoscopic ultrasound was done followed by a needle biopsy which confirmed a pancreatic head angiosarcoma followed by an ERCP and a stent placement. A CT abdomen done revealed a pancreatic head and uncinate tumor with a stent in the common bile duct. Patient underwent a pylorus preserving pancreaticoduodenectomy with an uneventful post-operative recovery. She defaulted her oncology appointments and was followed up with serial imaging. She developed a local recurrence 18 months after surgery and succumbed to her disease after 3 years. Pancreatic angiosarcoma is an aggressive tumor compared to other pancreatic malignancies. For a definite diagnosis of angiosarcoma, histopathologic and immunohistochemical analysis are necessary. Surgical resection offers the only possible cure, while oncological treatment has variable outcome. Currently, there are no treatment protocols available due to the small number of cases present in literature.

Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases

IntroductionThere is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. Patients and methodsA retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. ResultsMean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively. ConclusionsAlthough our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Clinical application of "Double R" anastomosis technique in laparoscopic pancreaticoduodenectomy procedure.

Laparoscopic pancreaticoduodenectomy (LPD) is widely used as a treatment for periampullary tumors and pancreatic head tumors. However, postoperative pancreatic fistula (POPF), which significantly affects mortality and length of hospital stay of patients, remains one of the most common and serious complications following LPD. Though numerous technical modifications for pancreaticojejunostomy (PJ) have been proposed, POPF is still the “Achilles heel” of LPD.To reduce POPF rate and other postoperative complications following LPD by exploring the best approach to manage with the pancreatic remnant, a novel duct-to-mucosa anastomosis technique named Double Layer Running Suture (Double R) for the PJ was established. During 2018 and 2020, a totally 35 patients who underwent LPD with Double R were included, data on the total operative time, PJ duration, estimated blood loss, recovery of bowel function, postoperative complications, and length of hospital stay were collected and analyzed.The average duration of surgery was (380 ± 69) minutes. The mean time for performing PJ was (34 ± 5) minutes. The average estimated blood loss was (180 ± 155) mL. The overall POPF rate was 8.6% (3/35), including 8.6% (3/35) for the biochemical leak, 0% (0/35) for Grade B, and 0% (0/35) for Grade C. No patient suffered from biliary fistula, post-pancreatectomy hemorrhage, and intra-abdominal infection, the 30-day mortality was 0%.Double R anastomosis is potentially a safe, reliable, and rapid anastomosis with a low rate of POPF and post-pancreatectomy hemorrhage. It provides surgeons more options when performing LPD. However, its safety and effectiveness should be verified further by a larger prospective multicenter study.

Margin ACcentuation for resectable Pancreatic cancer using Irreversible Electroporation – Results from the MACPIE-I study

IntroductionMargin accentuation (MA) using Irreversible electroporation (IRE) offers an unique opportunity to reduce the R1 resections in resectable pancreatic cancer (RPC). This study aims to assess the rate of margin positivity using IRE for MA during pancreaticoduodenectomy (PD) for resectable pancreatic head tumours. Materials and methodsFollowing ethical approval, MA using IRE was carried out in 20 consecutive patients to posterior and superior mesenteric vein (SMV) margin, and the pancreatic neck, prior to the PD resection. The control group (non-IRE; n = 91) underwent PD without MA over the study period, March 2018 to March 2020. ResultsThere was no difference between the two groups in terms of patients’ age, gender, pre-op biliary drainage, site of malignancy or pre-operative TNM stage. The overall margin positive rate for IRE group was lesser (35.0%) when compared to non-IRE group (51.6%; p = 0.177), with significantly less posterior pancreatic margin positivity (5.0% vs. 25.3%; p = 0.046). When only treated margins (SMA margin excluded) were compared, the IRE group had significantly lower margin positive rates (20.0% vs. 51.6%; p = 0.013). There was no difference between the two groups in terms of intra- or post-operative complications. With a median follow-up of 15.6 months, the median DFS and OS for IRE and non-IRE groups were 17 and 18 months (p = 0.306) and 19 and 22 months (p = 0.227) respectively. ConclusionOur pilot study confirms the safety of MA using IRE for RPC, with reduction in margin positivity. These results as a proof of concept are promising and need further validation with a randomised controlled trial.

Insights of Outcome after Resection of Small Nonfunctioning Neuroendocrine Pancreatic Tumors.

Background The incidence of small nonfunctioning neuroendocrine pancreatic tumors (NF-PNETs) has been increasing systematically in the last few decades. Surgical resection was once considered the treatment of choice but has been questioned in the direction of a more conservative approach for selected patients. Our aim was to analyze the outcome of surgical resection of small (≤3cm) NF-PNETs. Methods We retrospectively evaluated 14 patients with sporadic NF-PNETs who underwent pancreatic resection. Data were collected from patients' medical records. Results Of the 14 patients included, 35.71% were men, and the average age was 52.36 ± 20.36 years. Comorbidities were present in 92.86% of the cases. The incidence of postoperative complications was 42.86%, the 30-day mortality was zero, and the length of follow-up was 3.31 ± 3.0 years. The results of pathological evaluations revealed WHO grade I in 42.86% of cases, II in 21.43%, and neuroendocrine carcinoma in 35.71%. The median tumor size was 1.85cm (range, 0.5–3cm), and 2 cases had synchronous metastasis. The median TNM stage was IIa (range, I–IV). The disease-free and patient survival rates were 87.5% and 100% at 3 years and 43.75% and 75% at 10 years, respectively. The tumor pathological grade was significantly higher in head tumors than body-tail tumors, but there were no differences with respect to tumor size and TNM staging. Conclusion A surgical approach to treat small sporadic NF-PNETs is safe with low mortality and high patient survival. Based on these data, small pancreatic head tumors can be more aggressive, suggesting that surgical resection is still the best option to treat small nonfunctioning PNETS. Thus, conservative treatment should be indicated very cautiously for only cases with absolute contraindications for surgery.

ДУОДЕНУМ-СОХРАНЯЮЩАЯ РЕЗЕКЦИЯ ГОЛОВКИ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ ПРИ ХРОНИЧЕСКОМ ПАНКРЕАТИТЕ, ДОБРОКАЧЕСТВЕННЫХ И ПРЕДРАКОВЫХ ОПУХОЛЯХ ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ

Objective. To report the institutional experience of the evolution of duodenum-preserving pancreatic head resection (DPPHR) as a surgical treatment for chronic pancreatitis with an inflammatory tumor as well as cystic and benign, premalignant neoplasms and neuroendocrine tumors of the pancreatic head. Methods. DPPHR is associated with preservation of gastric antrum, common bile duct and duodenum/upper jejunal loop, contrary to Kausch-Whipple resection, which is a multivisceral procedure, including duodenectomy. Duodenum-preserving pancreatic head resection was first established in clinical setting in Berlin in 1969. Results. For chronic pancreatitis with an inflammatory infiltrat in the pancreatic head, duodenum-preserving pancreatic head resection has become a standard surgical treatment with worldwide acceptance. In a series of 603 patients with chronic pancreatitis following DPPHR, the frequency of pancreatic fistula was 3.3 %, intra-abdominal abscess 2.8 %, hemorrhage 2.8 %, frequency of reoperation 5.6%, in-hospital mortality 0.82 % and 90-day rehospitalisation 8 %. DPPHR for benign and premalignant cystic neoplasms of the pancreatic head is used predominantly for IPMN, MCN and SPN tumors. In a review of international publications comprising 503 patients, the general morbidity was 38.2 %, severe surgery-related complications 12.7% of them pancreatic fistula B+C 13.6 %, resurgery 2.7 % and 90-day mortality 0.4 %. When pancreatic neuroendocrine tumors of pancreatic head are treated with DPPHR, a local lymph node dissection is additionally recommended. The long-term morbidity following DPPHR revealed new onset of diabetes mellitus and exocrine dysfunctions in only 5-7 % of patients. Conclusion. Kausch-Whipple resection is associated with considerable high metabolic complications. Duodenum-sparing pancreatic head resection for inflammatory tumor, benign and premalignant neoplasms, and neuroendocrine tumors of the pancreatic head has the advantage of the duodenum preservation and maintenance of the pancreatic endocrine and exocrine functions.

Image-Guided Percutaneous Pancreatic Duct Drainage: A 10-Year Observational Study

PurposeTo study the safety, efficacy, and long-term outcomes of percutaneous pancreatic duct drainage (PPDD) for treating pancreatic duct (PD) obstruction. Materials and MethodsThis prospective observational cohort study included 73 patients with PD obstruction between December 2010 and June 2020. Patients underwent PPDD under ultrasound and fluoroscopy guidance, computed tomography (CT) and fluoroscopy guidance, or CT guidance only. They were categorized into 2 groups: nonmalignant (26 patients with PD obstruction due to acute and chronic pancreatitis or postoperative stricture) and malignant (47 patients with pancreatic head and ampullary tumors). ResultsThe overall technical success rate was 98.6% (72/73). No major complications were encountered; however, severe weakness, lack of appetite, and tachycardia were observed in 4.1% (3/73) of patients, managed with intravenous resuscitation. Multivariate analysis demonstrated that diagnosis type (pancreatic head tumor: P = .049; odds ratio = 1.95 [1.11–2.25], and chronic pancreatitis: P = .048; odds ratio = 6.25 [1.74–22.22]) was associated with mortality. The median survival time was 16.3 months. Moreover, 15.1% (11/73) of the patients were alive 4 years after the PPDD procedure, and the mean overall survival time of nonmalignant and malignant patients was 35.1 and 21.4 months, respectively. ConclusionsImage-guided PPDD appears to be feasible and safe and provides a valuable therapeutic option for managing patients with PD obstruction.

Pathologic upstaging in resected pancreatic adenocarcinoma: Risk factors and impact on survival.

Clinical and pathologic staging determine treatment of pancreatic cancer. Clinical stage has been shown to underestimate final pathologic stage in pancreatic cancer, resulting in upstaging. National Cancer Database was used to identify clinical stage I pancreatic adenocarcinoma. Univariate, multivariable logistic regression, and Cox proportional hazard ratio were used to determine differences between upstaged and stage concordant patients. Upstaging was seen in 80.2% of patients. Factors found to be significantly associated with upstaging included pancreatic head tumors (OR2.56), high-grade histology (OR1.74), elevated Ca 19-9 (OR2.09), and clinical stage T2 (OR1.99). Upstaging was associated with a 45% increased risk of mortality compared to stage concordant disease (HR1.44, p < .001). A majority of clinical stage I pancreatic cancer is upstaged after resection. Factors including tumor location, grade, Ca 19-9, and tumor size can help identify those at high risk for upstaging.

Median Arcuate Ligament Syndrome: an Important Consideration in Pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.

EXPERIENCE OF GASTROPANCREATODUODENAL RESECTION WITH CIRCULAR RESECTION OF MAJOR VENOUS VESSELS

Purpose of work. Improve patient outcomes in patients with pancreatic cancer.Material and methods of research. We present our own clinical observation of surgical treatment of malignant neoplasms of the head of the pancreas with invasion of the main venous vessels. In 2019, on the basis of 1 surgical Department of the GUZ Regional clinical oncological dispensary, 2 patients underwent gastropancreatoduodenal resections with circular portal vein resection and end-to-end angioplasty.The results of the study and their discussion. Tumor invasion into the main venous vessels is not a contraindication to performing radical surgery and is achievable when performing gastropancreatoduodenal resection, due to resections of the main venous vessels together with the tumor invading its wall.Conclusions. Resection of the portal vein together with the pancreatic head tumor invading its wall contributes to the achievement of radical surgery when performing gastropancreatoduodenal resection.

CLINICAL, BIOLOGICAL AND ENDOSCOPIC ULTRASOUND CHARACTERISTICS OF PANCREATIC CANCER IN CHO RAY HOSPITAL

Background: Pancreatic cancer is a common disease of digestive cancers. The tumor progresses rapidly and malignantly, showed a low 5-year survival rate. However, when diagnosed and treated early, the 5-year survival rate of pancreatic cancer improves significantly. Endoscopic ultrasound (EUS) has the advantage that probe can optimal access to the pancreas and surrounding organs, therefore, diagnose pancreatic tumors can be made even when the tumor is small (&lt; 2 cm). Furthermore, Endoscopic Ultrasound- Guided Fine needle aspiration (EUS-FNA) can determine the exact histology of the tumor. Objectives: 1. Investigate some clinical, biological and endoscopic ultrasound characteristics in patients with pancreatic cancer. 2. Evaluate the relationship between endoscopic ultrasound images with clinical and biological characteristics and compare the results between endoscopic ultrasound with computer tomography. Materials and methods: Descriptive cross-sectional studies in 58 patients with pancreatic cancer had endoscopic ultrasound. Results: In 58 patients with pancreatic cancer, we recorded that patients with a history of smoking accounted for 32.8%, and drinking alcohol 31%. Abdominal pain was 89.7%, 44.8% of patients show anorexia, 37.9% have weight loss. 69% of patients had CA 19-9 &gt; 37 UI/ml. EUS found a patient with pancreatic tumor &lt; 2 cm, but CT scan could not detect. Tumors in pancreatic head accounted for 60.3%; in the body 24.1%, 96.6% of pancreatic cancer have a hypoechoic structure, heterogeneous ultrasound. There was a significant relation between pancreatic head tumor and other part with jaundice (p = 0.013). Compatibility in diagnosis of vascular invasion between EUS and CT scan was average (K = 0.483). Conclusion: Smoking and alcohol consumption accounted for the highest proportion, abdominal pain was the most common clinical symptom. Endoscopic ultrasound can diagnose small pancreatic tumors that CT scan can not detect. Key words: Pancreatic cancer, endoscopic ultrasound, clinical characteristics, bio-marker

Clinical Significance of Preoperative Albumin–Bilirubin Grade in Pancreatic Cancer

No study has clarified the clinical significance of albumin-bilirubin (ALBI) grade in a large cohort of pancreatic cancer patients. A total of 1006 consecutive patients diagnosed with pancreatic cancer and deemed eligible for surgical resection were analyzed. The ALBI score was calculated as: ALBI score = (log10 bilirubin [µmol/L] × 0.66) + (albumin [g/L] × - 0.0852). ALBI grade was assigned as grade 1, 2a, 2b, and 3. ALBI grade 1 was assigned to the ALBI low group (N = 566), and grades 2a, 2b, and 3 to the ALBI high group (N = 440). The primary lesion could not be resected in 129 patients. Among all patients, overall survival (OS) was significantly worse in the ALBI high group than in the ALBI low group (P = 0.024). Overall, 877 patients underwent pancreatectomy. In these patients, the ALBI high group was associated with high CA19-9 level (P < 0.001), lower morbidity rate (P < 0.001), and pancreatic head tumor (P = 0.001). Patients' OS after resection was significantly worse in the ALBI high group than in the ALBI low group (P < 0.001). Cox proportional hazard analysis revealed ALBI grade as an independent predictor for prognosis (hazard ratio, 1.33; P = 0.015). Even in the CA19-9 negative patients, OS was significantly worse in the ALBI high group than in the ALBI low group (P = 0.046). The ALBI grade is a clinically useful predictor for prognosis in pancreatic cancer patients.

CT features predictive of nodal positivity at surgery in pancreatic cancer patients following neoadjuvant therapy in the setting of dual energy CT.

Evaluate utility of dual energy CT iodine material density images to identify preoperatively nodal positivity in pancreatic cancer patients who underwent neoadjuvant therapy. This IRB approved retrospective study evaluated 62 patients between 2012 and 2016 with proven pancreatic ductal adenocarcinoma, who underwent neoadjuvant therapy, tumor resection and both baseline and preoperative assessment with pancreatic multiphasic rapid switching dual energy CT. Three radiologists in consensus identified on imaging nodes > 0.5cm in short axis, evaluated nodal morphology, size and on each phase density in HU, and concentrations on iodine material density images normalized to the aorta. Of 62 patients, 33 were N0, 20 N1, and 9 N2. Total of 145 lymph nodes were evaluated, with average number of nodes per anatomic site ranging from 1.3 (body tumors) to 5 (uncinate) versus average of 24 and 30 nodes recovered respectively at surgery. Most (N = 44) were pancreatic head tumors. For all patients, regardless of site of primary tumor, the minimum measured iodine value of all of a patient's measured nodes taken as a group on preoperative studies, as normalized to the aorta, was significant at P = 0.041 value in differentiating N0 from N1/2 and ROC analysis showed an AUC of 0.67. With a cutoff of 0.2857, sensitivity was 0.78 and specificity was 0.58, with values < 0.2857 indicative of N1/2. Node morphology and changes in nodal size weren't statistically significant. The dual energy based minimum normalized iodine value of all nodes in the surgical field on preoperative studies has modest utility in differentiating N0 from N1/2, and generally outperformed conventional features for identifying nodal metastases.

Usefulness of 3D Digital Reconstruction in the Imaging Diagnosis of Pancreatic Tumors

Introduction: Reconstruction using 3D virtual models has brought about a revolution in diagnostic imaging and its use is increasingly widespread. The objective of this work is to determine the precision of the 3D model when establishing the characteristics of tumors and their relationship with other anatomical structures. Method: Three patients with suspected pancreatic tumor were included. 3D-MSP® technology (Cella Medical Solutions, Murcia, Spain) was used to make the 3D virtual models. Results: Case 1. A 79-year-old man with jaundice, postprandial dyspepsia and constitutional syndrome. CT, PET, MRI and endoscopic ultrasound did not show a mass. ERCP with biopsy of the papilla without malignancy. In the virtual model, a pancreatic head neoplasm was detected and surgery was then performed. A pancreatic head adenocarcinoma was found and it required pancreatectomy with portal resection. Case 2. 68-year-old woman with incidental finding of tumor in the pancreatic body. The CT scan showed no relationship between the tumor and vascular structures sodistal pancreatectomy was planned. However, the 3D scan showed infiltration of the portal vein (Figure 1B) and finally a cephalic pancreaticoduodenectomy with portal resection was performed. Case 3. 62-year-old woman who consulted for jaundice. CT reported a mass in the pancreatic head and PET-CT detected an abnormal uptake in the colon. The virtual model showed both tumors (Figure 1C) and they were resected. Conclusion: The use of 3D virtual models provides greater precision when locating the tumor and its extension, establishing vascular relationships and detecting inadvertent lesions. All this facilitates the planning of the surgery and allows the optimization of treatment.

Green Fluorescence Imaging (ICG) for the Study of Lymphatic Drainage in Pancreatic Head Tumors

Green Fluorescence Imaging (ICG) for the Study of Lymphatic Drainage in Pancreatic Head Tumors