Uncinate Research Articles

Robotic-assisted pancreatic enucleation: Posterior uncinate approach.

Functional pancreatic neuroendocrine tumors (pNET) necessitate surgical resection. Enucleation is the preferred surgical method for well-differentiated pNETs that measure less than 2cm in diameter, as it offers a greater likelihood of enhancing post-operative recovery and decreasing morbidity and mortality. Insulinomas are particularly suitable for enucleation when such a procedure is viable. However, enucleating tumors within the uncinate process of the pancreas, especially on its posterior aspect, can present substantial challenges. The accompanying video illustrates a robotic-assisted enucleation of an insulinoma in the uncinate process, performed on a 41-year-old male with recurrent hypoglycemia. This intervention led to the resolution of symptoms and incurred minimal post-operative morbidity.

The outcomes of robotic-assisted enucleation for tumors located in uncinate process of pancreas in 16 cases

Objective: To summarize the experience of robot-assisted enucleation of tumors located in uncinate process of pancreas. Methods: This is a retrospective case series study. The clinical data of patients with robot-assisted enucleation of tumors located in the uncinate process of pancreas at the Department of Gastroenterology and Pancreatic Surgery,Zhejiang Provincial People's Hospital from June 2019 to December 2023 were retrospectively analyzed. A total of 16 cases were enrolled,including 10 males and 6 females,with an age(M(IQR)) of 56(21)years (range: 28 to 77 years),and body mass index of 22.4(2.3)kg/m2 (range:19.8 to 25.6 kg/m2). Follow-up was asked every 6 to 12 months after the first 3-month postoperative follow-up through out-patient service or via telephone. Results: In total 16 cases,there were 11 cases with pancreatic enucleation,and 5 cases with resection of the uninate process. The operation time was 70(60) minutes (range: 40 to 165 minutes),and the blood loss was 30(13)ml (range: 10 to 80 ml). The rate of pancreatic fistula was 5/16. The length of stay was 8(6)days (range: 5 to 33 days). The pathological finding included non-functional neuroendocrine tumor(n=3),insulinoma(n=2),introductal papillary mucinous neoplasm (n=5),solid pseudopapillary neoplasm (n=2),mucinous cystadenoma (n=1),serous cystadenoma (n=2),pseudocyst (n=1). Follow-up as of March 12, 2024, the follow-up time was 16(12)months (range: 3 to 41 months). All patients had no new onset diabetes and no dyspepsia. Conclusion: Robot-assisted surgical system can be used for local resection of uncinate process tumors of pancreas,and the quality of life of patients can be improved.

Pancreaticoduodenectomy after postoperative gastric tube reconstruction for esophageal cancer with median arcuate ligament syndrome: a case report

BackgroundPancreaticoduodenectomy (PD) is considered a challenging surgery for resecting the gastroduodenal artery (GDA), right gastric artery (RGA), and lymph node tumors. In cases of pancreatic head cancer surgery, vascular anastomosis or right gastroepiploic artery (RGEA)/GDA preservation is necessary after postoperative gastric tube reconstruction for esophageal cancer. Therefore, we report for the first time an extremely rare case of PD in a patient with pancreatic head cancer and median arcuate ligament syndrome (MALS) after gastric tube reconstruction following esophageal cancer surgery, in which the entire pancreatic head arcade was preserved.Case presentationThe patient was a 76-year-old man who had undergone esophageal cancer surgery after sternal gastric tube reconstruction 7 years ago. He was referred to our hospital because of the suspicion of intraductal papillary mucinous carcinoma (IPMC) owing to an enlarged cystic lesion and a substantial component in the uncinate process of the pancreas. Preoperative three-dimensional computed (3D-CT) tomography angiography showed celiac axis stenosis and pancreatic head arcade dilation. The diagnosis was IPMC without evidence of invasion; therefore, gastric tube blood flow was maintained by preserving the GDA and RGEA. Due to MALS, the GDA blood flow was supplied through the pancreatic head arcade, necessitating its preservation. The GDA-RGEA, right gastroepiploic vein, and anterior superior pancreaticoduodenal artery were taped over the entire pancreatic head for preservation. The inferior pancreaticoduodenal artery (IPDA) was also taped on the dorsal pancreas and the posterior or anterior IPDA, which further bifurcates were taped to preserve them. Subsequently, PD was performed.ConclusionWe report a case of PD after gastric tube reconstruction for esophageal cancer with MALS, in which the pancreatic head arcade vessels were successfully preserved using 3D-CT to confirm the operation of the vessels.

Diagnostic Efficacy of Cell Block and Liquid-Based Cytology for Endoscopic Ultrasound-Guided Fine Needle Aspiration in Pancreatic Tumors.

This study aimed to evaluate the diagnostic efficacy of cell block (CB) and liquid-based cytology (LBC) for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic tumors. The study included patients who underwent EUS-FNA for pancreatic tumors between January 2015 and February 2021 and whose cytology samples were both processed for LBC and CB. Data of 390 patients (220 men, mean age: 64.2 ± 11.4 years) were retrospectively analyzed. Of the detected lesions (size: 17-120 mm; mean: 39.9 ± 13.9 mm), 220 (56.4%) were located in the head and uncinate process of the pancreas. Lesions in 339 (86.9%) patients were diagnosed as malignant using CB and/or LBC and suspicious for malignancy in 44 (11.3%) patients. In 7 patients with non-diagnostic (6 cases) or negative for malignancy (1 case) EUS-FNA results using both methods, the diagnosis of malignancy was established via ultrasound-guided percutaneous biopsy. Malignancy was detected in 324 (92.4%), 313 (87.9%), and 298 (87.9%) patients using CB, LBC, and both CB and LBC, respectively. Final diagnosis was obtained in 339 (98%) patients by using CB and/or LBC. The combined use of the both methods exhibited significantly superior diagnostic accuracy compared with CB and LBC alone (P < .001). Liquid-based cytology and CB exhibit high diagnostic accuracy for the detection of pancreatic tumors in patients undergoing EUS-FNA. The combined use of both methods showed a significantly higher diagnostic accuracy than LBC and CB alone.

Determinants of the uptake of the uncinate process of pancreas in 68Ga-DOTATOC PET/CT: a retrospective study

Purposean increased uptake of the uncinate process of pancreas (UPP) has been described in about one-third of somatostatin receptor imaging procedures and may hinder image interpretation. The determinants of this uptake are however poorly understood. The aim of this study was to investigate the impact of cold somatostatin analogues (cSA) on UPP 68Ga-DOTATOC uptake. Age and diabetic status were also studied.Methodsall adult patients who performed a 68Ga-DOTATOC PET/CT in our center between May 2021 and April 2023 were retrospectively screened. For each one, UPP uptake was visually assessed and measured using SUVmax. Clinical data including cSA medication, age and diabetic status were collected. Univariate and multivariate analyses were conducted using logistic regression. SUVmax comparisons were conducted using a Mann-Whitney Wilcoxon test.Results82 patients were included. UPP uptake was significantly lower in patients treated with cSA (OR 0.27, p = 0.015 in multivariate analysis), with a lower SUVmax (4.97 vs. 8.81, p = 0.001). No significant result was found regarding diabetic status or age.Conclusioncold somatostatin analog treatment decreased the physiological UPP uptake in 68Ga-DOTATOC PET/CT. This effect could be used to reduce interpretation errors in this location.

Insulinoma in the primary care: a case report

Insulinoma is an uncommon neuroendocrine tumor that can cause unspecific signs and symptoms. In this case report is presented a 79-year-old man with a history of diabetes and alcohol abuse. He presented several episodes of hypoglycemia with associated symptoms. Considering the alcoholic habits and the fact that he did not take hypoglycemic medication, it was considered that the alcohol abuse was the most probable cause. However, hypoglycemia didn’t stop after he stopped drinking and the hypothesis of an insulinoma has occurred. He was referred to hospital consultation, but due to the COVID-19 pandemic, he lost follow-up for almost 2 years. He had new episodes of hypoglycemia and was hospitalized. A nodule in the uncinate process of the pancreas was detected on CT scan and he was subjected to an elective cephalic duodenopancreatectomy. Hypoglycemia can be a manifestation of several diseases. Insulinoma can mimic several pathologies, making it a challenging diagnosis. This case intends to report the importance of the family doctor in the diagnosis of pathologies with nonspecific signs and symptoms, as well as the orientation for secondary health care.

Development of human pancreas

Pancreas is an exocrine and endocrine organ. Exocrine portion secretes digestive fluid. Endocrine portion secreting insulin and glucagon etc. Pancreas developed from dorsal and ventral pancreatic buds, which arise from either side of distal foregut. When duodenum rotates to right, ventral pancreatic bud(VPB) rotates posterior along with common bile duct(CBD) and finally lies below and behind the dorsal pancreatic bud(DPB). In humans, DPB forms major part and VPB forms inferior part of head and uncinate process of pancreas. Main duct (Duct of Wirsung) is derived from whole of ventral pancreatic duct(VPD) and distal part of dorsal pancreatic duct(DPD). Main duct joins with CBD and it perforated posteromedial side of second part of duodenum at major duodenal papilla. Occasionally accessory duct might originate from proximal part of DPD and open into minor papilla. Sometimes two buds do not fuse and lead to pancreatic divisum. Abnormal rotation and fusion of buds might lead to annular pancreas. A few endodermal pancreatic evaginations may remain and migrate in bowel wall and form accessory(heterotopic) pancreas. Islets originating from DPB have more insulin synthesis. Neck, body and tail of pancreas is supplied by coeliac trunk. Derivatives of right VPB are supplied by branches of superior mesenteric artery. During rotation of VPB, superior mesenteric vessels(SMV) were engaged in between DPB and VPB. Lastly, SMV is located posterior to neck but it is anterior to uncinate process of pancreas. Detailed study of development of exocrine and endocrine portions is required for successful management of pathology of the pancreas.

Continuous glucose monitoring in a patient with insulinoma presenting with unawareness of postprandial hypoglycemia.

Unawareness of postprandial hypoglycemia for 5 years was identified in a 66-year-old man at a local clinic. The patient was referred to our hospital because of this first awareness of hypoglycemia (i.e. lightheadedness and impaired consciousness) developing after lunch. In a 75 g oral glucose tolerance test, the plasma glucose concentration was decreased to 32 mg/dL (1.8 mmol/L) at 150 min with relatively high concentrations of insulin (8.1 μU/mL), proinsulin (70.3 pmol/L), and C-peptide (4.63 ng/mL). In a prolonged fasting test, the plasma glucose concentration was decreased to 43 mg/dL (2.4 mmol/L) at 66 h with an insulin concentration of 1.4 μU/mL and a C-peptide concentration of 0.49 ng/mL. Computed tomography showed an 18 mm hyperenhancing tumor in the uncinate process of the pancreas. A selective arterial calcium stimulation test showed an elevated serum insulin concentration in the superior mesenteric artery. The patient was then diagnosed with insulinoma and received pancreaticoduodenectomy. Continuous glucose monitoring (CGM) using the Dexcom G6 system showed unawareness of hypoglycemia mainly during the daytime before surgery. When the sensor glucose value was reduced to 55 mg/dL (3.1 mmol/L), the Dexcom G6 system emitted an urgent low glucose alarm to the patient four times for 10 days. Two months after surgery, an overall increase in daily blood glucose concentrations and resolution of hypoglycemia were shown by CGM. We report a case of insulinoma with unawareness of postprandial hypoglycemia in the patient. The Dexcom G6 system was helpful for assessing preoperative hypoglycemia and for evaluating outcomes of treatment by surgery. Insulinoma occasionally leads to postprandial hypoglycemia. The CGM system is useful for revealing the presence of unnoticed hypoglycemia and for evaluating treatment outcomes after surgical resection. The Dexcom G6 system has an urgent low glucose alarm, making it particularly suitable for patients who are unaware of hypoglycemia.

Intraductal papillary mucinous neoplasm of the accessory pancreatic duct in the pancreas uncinate process: A case report.

Intraductal papillary mucinous neoplasms (IPMN) of the accessory pancreatic duct (APD) are very rare and their clinical significance is not known. Here, we describe a case of IPMN originating in a branch of the duct of APD within the uncinate process of the pancreas, which initially presented with acute pancreatitis. A 70-year-old man visited our medical center presenting with acute pancreatitis around the head and uncinate process of the pancreas. Computer tomography scans revealed the presence of a 35-mm cystic mass-like lesion within the pancreas uncinate process communicating with a branch of the APD. The patient was diagnosed with APD-IPMN in the pancreas uncinate process accompanied by acute pancreatitis. Conservative management of the acute pancreatitis relieved his symptoms, while duodenum-preserving partial pancreatic head resection (DPPHR-P) was performed to treat the APD-IPMN. Intraoperative exploration showed the presence of severe adhesions within the uncinate process of the pancreas and that the tumor's "peduncle" - a branch of the duct of APD - was saddling just at the front of the main pancreatic ducts. Thus, surgical removal of the tumor required special handling of the region between the main duct (MD) and APD to protect the integrity of the main pancreatic ducts. Finally, a 35*30*15 mm IPMN was successfully removed and the MD was preserved combined with ligation from the root of the APD of the pancreas. The drainage volume of the ventral tube increased by around 20-fold in 24 hours on the fourth day after surgery. The presence of high amylase levels in the drainage discharge (40713.5 U/L) led to the diagnosis of postoperative pancreatic fistula (POPF). The drainage volume remained high for 3 days. The patient was discharged and POPF was successfully managed through endoscopic pancreatic duct stenting. APD-IPMN in the pancreas uncinate process has its own characteristics of localized pancreatitis, and MD-preserving DPPHR-P not only protects the exocrine and endocrine functions of the pancreas, but it also protects the physiological and anatomical integrity. The appearance of POPF after DPPHR-P may be managed by endoscopic pancreatic duct stenting.

Experiencia en la resección del proceso uncinado del páncreas: indicaciones y resultados. Revisión de la literatura

IntroductionThe aim of our study is to assess the accumulated experience in the use of uncinatectomy (UC) as a parenchymal-sparing pancreatectomy technique. MethodWe have carried out a observational and descriptive study including restrospectively all the patients undergoing UC at Hospital Universitary de Bellvitge (HUB) and an exhaustive review of the cases described in the english literature. ResultsFrom 2003 to 2019, seven patients have been operated by UC in the HUB with a diagnostic orientation of pancreatic lesion considered premalignant. All patients have presented morbidity, mainly in the form of postoperative pancreatic fistula, and none of them have presented endocrine or exocrine pancreatic insufficiency. Currently, all patients are alive and without recurrence of neoplastic disease. Another 29 cases have been described in the literature. Of all the cases (36 patients), the approach was minimally invasive (laparoscopic or robotic) in 6 patients (16.7%), leading to a shorter hospital stay. The global incidence of pancreatic fistula is 50%, with a re-admission rate of less than 10%, but without requiring re-intervention. ConclusionUC is an infrequent and poorly standardized technique for the resection of benign lesions or those with low potential for malignancy located in the uncinate process of the pancreas. Although it is associated with equal or greater morbidity than standardized resection techniques, it offers excellent preservation of endocrine and exocrine pancreatic function, with the consequent long-term benefit in the patients life quality.

Collision of Ductal Adenocarcinoma and Sarcoma Tumor of the Pancreas: A Case Report

We describe a clinical case of a 64-year-old woman with the diagnosis of obstructive jaundice due to a lesion located on the uncinate process of pancreas, with the final anatomy-pathological diagnosis of pancreatic carcinosarcoma, a rare subtype of pancreatic cancer with limited clinical and pathologic data reported in the literature.

LBODP070 A Rare Neuroendocrine Tumor-Insulinoma

Abstract Introduction Insulinoma is a rare neuroendocrine tumor, which presents sporadically or as a complex of multiple endocrine neoplasia type 1 syndrome (MEN-1). Most Insulinoma cases present with fasting hypoglycemia and some with both fasting and postprandial hypoglycemia. Case Report A 48-year-old male with no significant past medical or surgical history presented for an evaluation of hypoglycemia. He was recently seen in the Emergency Room after having a transient ischemic attack-like episode. The patient reported that he was at a family gathering where he was found confused and his blood glucose was checked by a family member with diabetes, which was noted to be 39 mg/ dl. He reported having other such episodes of lesser severity, occurring once or twice a month for many years. His symptoms would typically wake him from sleep, especially during early mornings with diaphoresis. He would take a snack to resolve his symptoms. Except for being overweight, no other abnormal findings were detected on physical examination. Fasting blood work revealed glucose of 42 with elevated insulin, C-peptide, proinsulin levels, and negative beta-hydroxybutyrate and insulin antibodies. An MRI abdomen with contrast demonstrated a 1.2 cm pancreatic lesion in the uncinate process, suspicious for a neuroendocrine tumor. Endoscopic Ultrasound staged the mass in the uncinate process of the pancreas as T1 N0 M0. FNAC showed a few atypical monomorphic cells suggestive of neuroendocrine origin. Immunohistochemical stains on the sample were positive for CD45 while CAM5.2, synaptophysin, and Ki65 were negative. The patient ultimately underwent exploratory laparotomy and resection of the neuroendocrine tumor with partial pancreatectomy. Discussion The symptoms of hypoglycemia are classified into sympathoadrenal (palpitation, diaphoresis, tremulousness) or neuroglycopenic (confusion, blurry vision, change in behavior, seizures, and amnesia of hypoglycemic episode). The neuroglycopenic symptoms of hypoglycemia mimic transient ischemic attack (TIA). The diagnosis of insulinoma needs biochemical proof of endogenous hyperinsulinemia and localization of the tumor. Surgery is the treatment of choice in resectable tumors. Conclusion This case highlights insulinoma as a rare cause of hypoglycemia and shows the importance of detailed history taking and appropriate investigations in its diagnosis.

S2882 Uterine Cervical Squamous Cell Carcinoma: A Rare Cause of Biliary Obstruction

Introduction: The incidence of biliary obstruction is 5 cases per 1000 people in the United States with reports of 21% caused by metastatic lesions to the pancreaticobiliary system. Metastatic lesion to the pancreas is rare, with few cases on uterine squamous cell cancer (SCC) metastasizing to the pancreas. We present a case report of a uterine cervical SCC with metastasis to the pancreas resulting in biliary obstruction. Case Description/Methods: A 51-year-old female with a history of stage 4b uterine cervical SCC previously treated with radiation and chemotherapy six years prior presented with elevated aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP) levels two times the upper limit of normal and jaundice. Prior to presentation she was in remission. However, CT on presentation demonstrated new thickening of the midthoracic esophagus, with subcarinal lymphadenopathy and a 1.9 x 2.2 cm mass in the uncinate process of the pancreas causing biliary dilation. Follow-up PET imaging showed evidence of a new intense uptake in the pre-carinal space and new pancreatic head involvement (Figure 1a). She simultaneously underwent an Endoscopic Ultrasound (EUS) and Endoscopic retrograde cholangiopancreatography (ERCP) for stent placement (Figure 1b). EUS showed a 21 mm x 20 mm hypoechoic lesion at the pancreatic head/uncinate process (Figure c). A fine needle biopsy was performed. Pathologic evaluation was consistent with a metastatic lesion secondary to a keratinizing SCC subtype was identified. (Figure d). Discussion: Metastasis to the pancreas accounts for 2-5% of pancreatic malignancies. Majority of SCC are associated with cervical high risk-human papilloma virus (HPV) with HPV-16 and HPV-18 being responsible for the most common types of cervical cancers. To date there have been only two published reports in the literature on SCC of the uterine cervix metastasizing to the pancreas. This case report emphasizes the importance of differentiating primary pancreatic carcinomas from metastatic lesions to the pancreas from other primary sources. There are various imaging modalities for diagnosis such as PET, CT, MRI/MRCP, ultrasonography, and EUS. In our case we were able to identify a new mass in the pancreas with CT, MRI and PET imaging and diagnose it with EUS. The usage of EUS to achieve accurate histopathologic diagnosis is becoming more important to tailor specific management and treatment options for pancreatic tumorsFigure 1.: a: PET avid lesion; b: Stricture as seen on ERCP within the distal CBD; c: Pancreatic mass on EUS; d: pancreatic tissue involved by sheets of cells with round to oval and angulated nuclei, moderate amounts of dense eosinophilic cytoplasm, intercellular bridges, and focal keratin formation. Scattered mitoses, dyskeratotic keratinocytes and apoptotic debris

Functional Insulinomas in a Rhesus Macaque (Macaca mulatta)

We report a rare case of functional insulinomas in a 16.7-year-old female Rhesus macaque (Macaca mulatta) that was presented with neuroglycopenic signs to the breeding colony hospital at the Tulane National Primate Research Center. At initial and follow-up examinations, the animal was consistently hypoglycaemic and was clinically maintained with additional fruits, other high-sugar food items and dextrose supplementation. Occasional episodes of seizure and collapse resolved quickly on administration of high-sugar food items. At necropsy, the uncinate process of the pancreas had a 2.2cm diameter, red, round, firm neoplastic mass, and another neoplasm was identified on histological examination of the head of pancreas. Histologically, neoplastic cells exhibited neuroendocrine packeting, resembled pancreatic islet cells and immunolabelled for chromogranin A, synaptophysin and insulin but not for somatostatin, gastrin or pancreatic polypeptide. A few cells immunolabelled for glucagon. The clinical signs and gross and histological findings were consistent with functional insulinomas.

Da Vinci robotic assisted pancreaticoduodenectomy with superior mesenteric vein resection and reconstruction

This study demonstrated Da Vinci robot assisted pancreaticoduodenectomy with superior mesenteric vein (SMV) resection and reconstruction. The patient was diagnosed with pancreatic head cancer preoperatively. After anesthesia, trocars were placed by “six-hole method”, and then constant pressure pneumoperitoneum was established. The first step was to remove the gallbladder, open the gastrocolonic ligament, and expose the pancreas and surrounding tissues. After making a Kocher incision, we dissected duodenum, inferior vena cava and uncinate process of pancreas, and then cleaned lymph nodes in groups 13 and 16A. After the stomach was severed using linear stapler, the right gastric artery was dissected and ligated. In this case, the adhesion around the pancreas and common hepatic artery was serious, so the pancreas was transected firstly. The gastroduodenal artery was dissected from the upper edge of the pancreas, and the lymph nodes in groups 7, 8, 9 and 12 were cleaned to expose the common bile duct and portal vein. The common bile duct was transected above the confluence plane of the cystic duct. After opening the colonic mesentery on the left side of the superior mesenteric artery (SMA), the jejunum was severed with a linear cutting obturator. The uncinate process was treated through the middle artery approach; the inferior pancreaticoduodenal artery was severed and lymph nodes were cleaned to the root of SMA and celiac trunk. The tumor and part of the invaded SMV were removed and end-to-end SMV anastomosis was performed. The proper hepatic artery was wrapped with the round hepatic ligament. To protect the stump of gastroduodenal artery, we padded the round hepatic ligament below the pancreaticoduodenal anastomosis. The modified Blumgart method was used for pancreaticointestinal duct to mucosal anastomosis. 4-0 ​V-Lock suture was used for continuous suture of posterior wall and anterior wall respectively, and finally gastrointestinal side-to-side anastomosis was performed. The operation time was 360 ​min and the intraoperative bleeding was 200 ​mL. The patient was discharged 7 days after operation.

147 Synchronous Parathyroidectomy and Extended Thymectomy in Multiple Endocrine Neoplasia Type 1- a Case Report

Abstract In recent decades there has been a significant advancement in the management of neuroendocrine tumours (NETs) associated with multiple endocrine neoplasia type 1 (MEN-1). Hormone excess accounted for 75% of all MEN-1 deaths, however since the introduction of hormone blocking medication, deaths in patients with MEN-1 are now predominantly due to the malignant effects of the tumours. Half of all MEN-1 related deaths are due to tumours that are difficult to diagnose, including thymic NETs. Complete surgical resection is the mainstay of treatment for MEN-1 associated thymic NETs. The case patient was a 49-year-old male who was being investigated for a 3-month history of symptoms consistent with hypercalcaemia. Initially a chest X-ray demonstrated a large anterior mediastinal mass. Further imaging revealed parathyroid lesions and a calcified lesion in the uncinate process of the pancreas. This combination of symptoms and radiological evidence raised the possibility of MEN-1 as the diagnosis. The lesions were biopsy-proven atypical carcinoid NETs and the patient later underwent simultaneous neck dissection for bilateral subtotal parathyroidectomy and a midline sternotomy for total thymectomy of the large mediastinal mass. Further testing revealed the pancreatic mass was another primary tumour and the patient is scheduled for excision of this. In addition, the patient is also being treated with Lanreotide alongside chemotherapy. Mutation of the MEN-1 gene was later confirmed on genetic testing. Due to the increase in mortality from neuroendocrine malignancy, it is becoming ever more important to understand how to manage multiple NETs from a surgical perspective.

Percutaneous ultrasound and endoscopic ultrasound-guided biopsy of solid pancreatic lesions: An analysis of 1074 lesions

BackgroundsPercutaneous ultrasound (US) and endoscopic ultrasound (EUS)-guided pancreatic biopsies are widely accepted in the diagnosis of pancreatic diseases. Studies comparing the diagnostic performance of US- and EUS-guided pancreatic biopsies are lacking. This study aimed to evaluate and compare the diagnostic yields of US- and EUS-guided pancreatic biopsies and identify the risk factors for inconclusive biopsies. MethodsOf the 1074 solid pancreatic lesions diagnosed from January 2017 to February 2021 in our center, 275 underwent EUS-guided fine needle aspiration (EUS-FNA), and 799 underwent US-guided core needle biopsy (US-CNB/FNA). The outcomes were inconclusive pathological biopsy, diagnostic accuracy and the need for repeat biopsy. All of the included factors and diagnostic performances of both US-CNB/FNA and EUS-FNA were compared, and the independent predictors for the study outcomes were identified. ResultsThe diagnostic accuracy was 89.8% for EUS-FNA and 95.2% for US-CNB/FNA (P = 0.001). Biopsy under EUS guidance [odds ratio (OR) = 1.808, 95% confidence interval (CI): 1.083-3.019; P = 0.024], lesion size < 2 cm (OR = 2.069, 95% CI: 1.145-3.737; P = 0.016), hypoechoic appearance (OR = 0.274, 95% CI: 0.097-0.775; P = 0.015) and non-pancreatic ductal adenocarcinoma carcinoma (PDAC) diagnosis (OR = 2.637, 95% CI: 1.563-4.449; P < 0.001) were identified as factors associated with inconclusive pathological biopsy. Hypoechoic appearance (OR = 0.236, 95% CI: 0.064-0.869; P = 0.030), lesions in the uncinate process of the pancreas (OR = 3.506, 95% CI: 1.831-6.713; P < 0.001) and non-PDAC diagnosis (OR = 2.622, 95% CI: 1.278-5.377; P = 0.009) were independent predictors for repeat biopsy. Biopsy under EUS guidance (OR = 2.024, 95% CI: 1.195-3.429; P = 0.009), lesions in the uncinate process of the pancreas (OR = 1.776, 95% CI: 1.014-3.108; P = 0.044) and hypoechoic appearance (OR = 0.127, 95% CI: 0.047-0.347; P < 0.001) were associated with diagnostic accuracy. ConclusionsIn conclusion, both percutaneous US- and EUS-guided biopsies of solid pancreatic lesions are safe and effective; though the diagnostic accuracy of EUS-FNA is inferior to US-CNB/FNA. A tailored pancreatic biopsy should be considered a part of the management algorithm for the diagnosis of solid pancreatic disease.

PANCREATIC TUBERCULOSIS: A RARE DIAGNOSIS BY ENDOSCOPIC ULTRASOUND GUIDED FNAC

Introducation: Tuberculosis remains a threat to global public health and is the top infectious cause of death globally. The burden of extrapulmonary tuberculosis (EPTB) is high, ranging from 15-20% of all TB cases in HIV negative patients while in HIV positive people, it account for 40-50% of new TB cases. Abdominal TB cases makes up about 3 % of all EPTB cases in India. In abdominal tuberculosis, Ileocaecal region is most commonly affected; solid organs like kidney, spleen and liver get involved with Tuberculosis much more commonly than the pancreas. Pancreatic tuberculosis is very rare even in regions with high prevalence of tuberculosis. Pancreatic tuberculosis most commonly aficts the region of the head and the uncinate process of the pancreas. It is often misdiagnosed due to low index of suspicion and masquerading of its symptoms as pancreatic malignancy. Case Presentation: A 67 years old male presented to the physician with a history of pain abdomen in umbilical region. Ultrasound whole abdomen demonstrated mildly bulky pancreas with ill dened hypoechoic lesion in the body region. Endoscopic ultrasound-guided ne needle aspiration (EUS-FNA) of the lesion was performed and cytology revealed numerous acid fast bacilli with necrotic material in background of red blood cells. Abdominal computed tomography (CT) scan was done which was suggestive of well- dened non enhancing multiloculated lesions of body of pancreas with evidence of necrotic lymph node in pre and left para-aortic region. Antitubercular treatment was started accordingly. Conclusion: Pancreatic tubercuklosis may present as pancreatic abscess, pancreatitis,or acystic or solid pancreatic mass. The use of EUS-FNA has become essential tool in the evaluation of pancreatic lesion.

Experience in the resection of the uncinate process of the pancreas: Indications and results. Literature review

Experience in the resection of the uncinate process of the pancreas: Indications and results. Literature review

Minimally Invasive Resection of the Uncinate Process of the Pancreas: Anatomical Considerations and Surgical Technique.

Low-grade lesions may benefit from pancreatic-sparing techniques. Resection of the uncinate process is rarely performed and reported due to its complexity that requires careful patient selection and accurate knowledge of the pancreatic anatomy. This study describes relevant anatomical elements to safely perform this complex operation in the minimally invasive setting. In this study, consecutive patients undergoing resection of the uncinate process of the pancreas were studied. Patients undergoing open approach were used for comparison. Preoperative and intraoperative variables were recorded, and the diagnosis and tumor size were determined from the pathology reports. Immediate postoperative results and hospital stay were analyzed. Follow-up was used to assess long-term complications and endocrine and exocrine functions. Twenty-nine patients underwent resection of the uncinate process. The median age was 57 years. There were 21 males and eight females. Twenty patients underwent minimally invasive resection (14 laparoscopic and six by robotic approach) and nine were operated by open approach. A clinically relevant postoperative pancreatic fistula was observed in one patient (3.4%). Biochemical leakage was present in 44.8% of our patients. Mean follow-up was 62 months (3-147). Two patients needed reoperation during follow-up. No patient presented exocrine or endocrine insufficiency during late follow-up. Minimally invasive resection of the uncinate process of the pancreas is a complex but a feasible procedure that preserves the pancreatic endocrine and exocrine functions. This pancreas-sparing procedure is an interesting alternative to pancreaticoduodenectomy in selected patients.