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A 51-year-old man underwent diagnostic work-up for an abnormal-appearing ampulla of Vater. Three hours after biopsy of the ampulla, the patient presented with intense symptoms suggesting acute pancreatitis, which was later confirmed with laboratory and radiographic examinations. Other causes were excluded and the acute pancreatitis was considered a procedural complication. This is a rarely reported complication that must be taken into consideration when biopsies are performed in the ampulla of Vater.

Breast cancer is the most common tumor in women and the first cause of death for malignancy in the female. Bile ducts are not among the common sites of metastasis from breast cancer. Few cases of obstructive jaundice due to metastatic breast cancer have been described in the literature and they mostly resulted from widespread liver metastases that eventually involved the bile ducts. We report an exceptional case of ampullary metastasis in the absence of liver metastases. Sporadic reports have been published about the involvement of the ampulla by breast cancer metastasis. This case emphasizes the need to consider this diagnosis in women presenting with obstructive jaundice, especially when there is a clinical possibility of breast cancer.

BACKGROUND The cause of common bile duct (CBD) dilatation cannot be determined by imaging modalities in many patients. The aim of this study was to assess the value of endoscopic ultrasonography (EUS) in detecting the cause of CBD dilatation in patients in whom ultrasonography could not demonstrate the cause of dilation. METHODS Prospectively, 152 consecutive patients who were referred for evaluation of dilated CBD (diameter ≥7 mm) of undetermined origin by ultrasonography were included in this study. All the patients underwent EUS. Final diagnoses were determined by using endoscopic retrograde cholangiopancreatography (ERCP), EUS guided fine needle aspiration (FNA), surgical exploration, or follow-up for at least 10 months. Patients with choledocholithiasis were referred for ERCP and sphincterotomy, and patients with operable tumors were referred for surgery. Patients with inoperable tumors underwent biliary stenting with or without chemoradiotherapy. RESULTS 152 patients (54% female) with dilated CBD were included. Mean (±SD) age of the patients was 60.4 (±17.3) years. The mean CBD diameter for all study group in transabdominal ultrasonography and EUS were 11.7 millimeter and 10.1 millimeter, respectively. Most of the patients with dilated CBD and abnormal liver function test (LFT) had an important finding in EUS and follow-up diagnosis including peri-ampullary tumors. Mean diameter of CBD in patients with and without abnormal LFT were 10.5 IU/L and 12.1 IU/L, respectively. Final diagnoses included choledocholithiasis in 32 (21.1%), passed CBD stone in 35 (23%), opium-induced CBD dilation in 14 (9.2%), post-cholecystectomy states in 20 (13.1%), ampullary adenoma/carcinoma in 15 (15.8%), cholangiocarcinoma in 14 (9.2%), and pancreatic head cancer in 9 (5.9%) patients. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS for patients with abnormal EUS were 89.5%, 100.0%, 100.0%, 91.2%, and 90.9%, respectively. CONCLUSION After diagnosis of CBD dilation by transabdominal ultrasonography, EUS may be a reasonable choice for determining the etiology of dilated CBD and tumor staging.

Gastrointestinal stromal tumours (GISTs) account for less than 1% of all gastrointestinal tumours. It mainly involves the stomach and small intestines and very rarely involves the ampulla of Vater. Endoscopic biopsy and endoscopic ultrasound allow for preoperative tissue diagnosis and local evaluation of the ampullary lesions. We herein report the case of a patient with GIST of the ampulla of Vater presenting with gastrointestinal bleeding and undergoing pancreaticoduodenectomy. The management of ampullary GIST is reviewed. [ABSTRACT FROM AUTHOR]

ABSTRACT Background: Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. Aim: To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. Method: Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. Results: Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). Conclusion: There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

Background: The prognostic utility of Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) in ampullary adenocarcinoma is unclear. We sought to evaluate the association between initial tumor marker levels and survival in patients with resected ampullary adenocarcinoma., Methods: This was a single-institution, retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma from 1999 to 2021. CA 19-9 was assessed after biliary decompression. Contal and O'Quigley method determined optimal biomarker cutoff levels which were correlated with overall survival (OS) using the Kaplan-Meier method and Cox Proportional Hazards Regression., Results: A total of 180 patients underwent pancreatoduodenectomy. Patients with CA 19-9 >100 U/mL had a shorter median OS (28 vs. 132 months, p < 0.001) compared to patients with CA 19-9 ≤ 100 U/mL at diagnosis. Survival was similar between pancreaticobiliary and intestinal tumor subtypes when CA 19-9 was >100 U/mL (OS:25 vs. 33 months, p = 0.415). By Cox regression analysis, CA 19-9 >100 U/mL was independently associated with worse OS (HR 2.8, p = 0.001)., Conclusions: Preoperative CA 19-9 >100 U/mL was associated with shorter OS in patients with resected ampullary adenocarcinoma. CA 19-9 may be useful when counseling patients about prognosis or when considering the role of perioperative systemic therapy., (Copyright © 2023. Published by Elsevier Ltd.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Backgrounds/aims: In 2019, the grading and staging system for neuroendocrine neoplasms (NENs) was significantly changed. In this study, we report the clinicopathological characteristics and surgical outcomes of patients with extrahepatic biliary NENs who underwent curative resection with or without adjuvant treatment., Methods: We retrospectively reviewed a database of 16 patients who developed NENs, neuroendocrine carcinoma (NEC), and mixed endocrine non-endocrine neoplasms (MiNENs) after curative resection. Among them, eight patients had ampulla of Vater (AoV) tumors, and eight patients had non-AoV tumors., Results: G1 and G2 were more frequently observed in the AoV group than in the non-AoV group (12.5% and 62.5%, respectively). In contrast, NEC and MiNEN were more common in the non-AoV group (50.0%). High Ki-67 index (> 20%) and perineural invasion (PNI) were more frequently observed in the non-AoV group. Advanced age (> 65 years), mitotic count > 20 per 2 mm 2 , and Ki-67 index > 20% were strongly correlated with patient survival ( p = 0.018, 0.009, and 0.044, respectively). Advanced age (> 65 years) and mitotic count > 20 per 2 mm 2 were significantly correlated with disease recurrence ( p = 0.033 and 0.010, respectively)., Conclusions: AoV and non-AoV tumors had significant differences in the histologic grade, Ki67, and PNI. Patients with non-AoV tumors had an increased risk for survival and recurrence than those in the AoV group. For extrahepatic biliary NENs, early detection of tumors, adequate surgery, and aggressive adjuvant treatment for high-risk patients are important to achieve long-term survival and prevent disease recurrence.

Introduction: To investigate the application potential of single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures ("1 + 2" PJ) in total laparoscopic pancreaticoduodenectomy (TLPD). Explore the advantages of "1 + 2" PJ over the traditional double-layer interrupted duct-to-mucosa pancreaticojejunostomy (traditional PJ)., Methods: We retrospectively collected the clinical data of 184 patients who were admitted in our department from Oct 2019 to Oct 2022, including 95 cases who underwent TLPD with "1 + 2" PJ and 89 cases who underwent TLPD with traditional PJ. The pre/intra/postoperation data were analyzed and compared., Results: The "1 + 2" PJ procedures were successfully performed in all the 95 cases. When compared with the traditional PJ group, there were no statistically significant variations between the pre-operative and pathological data. However, the "1 + 2" PJ group had a shorter operation time (235 (210, 300) minutes vs. 310 (270, 360) minutes in the traditional PJ group, P < 0.001), shorter pancreaticojejunostomy time (15 (10, 20) minutes vs. 50 (45, 55) minutes in the traditional PJ group, P < 0.001), lower pancreatic fistula (both grade B/C) rate (4.21% vs. 12.34% in the traditional group, P = 0.044), and abdominal infection rate (2.11% vs. 8.99% in the traditional group, P = 0.044), as well as reduced hospital stay (11 (9, 15) days vs. 13 (11, 15) days in the traditional PJ group, P = 0.013). In the "1 + 2" PJ group, the median diameter of the pancreatic duct was 3 (3, 4) mm; 82 cases (86.31%) had a normal pancreatic texture, while nine (9.47%) cases had a hard texture, and seven (7.37%) cases had a soft texture; the median intraoperative blood loss was 200 (100, 400) mL and 19 cases (20.00%) needed intraoperative transfusion; eight cases (8.4%) developed postoperative complications, including four cases (4.2%) of pancreatic fistula (including both grade B/C), one case (1.1%) of bile leakage, three cases (3.2%) of delayed gastric emptying, three cases (3.2%) of postoperative hemorrhage, two cases (2.1%) of abdominal infection, and one case (1.1%) of reoperation; the median hospital stay was 13 (8, 17) days; 25 cases were pathologically classified as pancreatic cancer, 35 cases as bile duct cancer, 23 cases as duodenal cancer, and 12 cases as ampullary cancer., Conclusion: Single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures is a feasible and safe procedure that can be applied in TLPD., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aims: EUS-guided gallbladder drainage (EUS-GBD) with lumen-apposing metal stents (LAMSs) has been reported as a rescue treatment with encouraging results for the relief of jaundice in patients with distal malignant biliary obstruction (DMBO) and after failure of both ERCP and EUS-guided choledochoduodenostomy., Methods: This was a multicenter retrospective analysis of all cases of consecutive EUS-GBD with LAMSs used as a rescue treatment for patients with DMBO in 14 Italian centers from June 2015 to June 2020. Primary endpoints were technical and clinical success, whereas the secondary endpoint was the adverse event (AE) rate., Results: Forty-eight patients (52.1% women) with a mean age of 74.3 ± 11.7 years were included in the study. Biliary stricture was related to pancreatic adenocarcinoma (85.4%), duodenal adenocarcinoma (2.1%), cholangiocarcinoma (4.2%), ampullary cancer (2.1%), colon cancer (4.2%), and metastatic breast cancer (2.1%). The mean diameter of the common bile duct was 13.3 ± 2.8 mm. LAMSs were placed transgastrically in 58.3% of cases and transduodenally in 41.7%. Technical success was 100%, whereas clinical success was 81.3%, with a mean total bilirubin reduction after 2 weeks of 66.5%. The mean procedure time was 26.4 minutes, and the mean hospital stay was 9.2 ± 8.2 days. AEs occurred in 5 patients (10.4%): 3 were classified as intraprocedural and 2 were classified as delayed because they occurred after >15 days. When the American Society for Gastrointestinal Endoscopy lexicon was used, 2 AEs were mild and 3 were moderate (2 buried LAMSs). The mean follow-up was 122 days., Conclusions: Our study shows that EUS-GBD with LAMSs used as a rescue treatment for patients affected by DMBO represents a valuable option in terms of technical and clinical success rates, with an acceptable AE rate. To the best of our knowledge, this is the largest study concerning the use of this procedure. (Clinical trial registration number: NCT03903523.)., Competing Interests: Disclosure The following authors disclosed financial relationships: C. Binda: Lecturer for Steris, Fujifilm, and Q3 Medical. A. Anderloni: Consultant for Boston Scientific, Olympus, and Medtronic. A. Fugazza: Consultant for Boston Scientific and Olympus. A. Repici: Consultant for Boston Scientific, Fujifilm, and ERBE. C. Fabbri: Lecturer for Steris and Q3 Medical; consultant for Boston Scientific. R. Di Mitri: Consultant for Boston Scientific. All other authors disclosed no financial relationships., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

The ampulla of Vater is a small projection formed by the confluence of the main pancreatic duct and common bile duct in the second part of the duodenum. Primary ampullary adenocarcinoma is a rare malignancy, accounting for only 0.2% of gastrointestinal cancers and approximately 7% of all periampullary cancers. Jaundice from a biliary obstruction is the most common symptom of ampullary adenocarcinoma. In the early stages, radical pancreatoduodenectomy is the standard surgical approach. On the other hand, no randomized controlled trial has provided evidence to guide physicians on the choice of adjuvant/palliative chemotherapy because of the rarity of the disease and the paucity of related research. This paper reports the biology, histology, current therapeutic strategies, and potential future therapies of ampullary adenocarcinoma.

Background/aims: Pancreatic and ampullary adenocarcinoma (AAC) are quite resistant to chemotherapy with high metastasis potential. Our study aimed to interpret high-mobility group A protein 2 (HMGA2) expression in benign and precursor pancreatic lesions and pancreatic and ampullary carcinoma and to evaluate its relationship with epithelial-mesenchymal transition (EMT) and clinicopathological parameters., Materials and Methods: In this study, normal-appearing pancreas, chronic pancreatitis (CP), low- (L) and high (H)-grade pancreatic intraepithelial neoplasia (PanIN), pancreatic ductal adenocarcinoma (PDAC), and AAC were evaluated with the immunohistochemical marker of HMGA2. Vimentin and E-cadherin immunohistochemical stains were applied in PDAC and AAC., Results: The HMGA2 expression was not detected in normal-appearing pancreas, CP, and L-PanIN. A statistically significant expression was observed in PDAC and H-PanIN (P < .001). A statistically significant correlation was found between loss of membranous E-cadherin expression and vimentin positivity and HMGA2 expression (P > .05). The HMGA2 expression was observed to increase the risk of diseaserelated death and decrease overall survival (OS) in AAC and the neoplasia group (P = .002 and P = .016, respectively). There was no significant difference in OS and risk of death in PDAC (P > .05) with respect to HMGA2 positivity., Conclusion: High-mobility group A protein 2 is a helpful immunohistochemical marker in differentiating CP from PDAC. It also plays a role in EMT and may serve as a potential new prognostic agent and therapeutic target in tumors of the periampullary region, especially AAC.

Rapidly increase of medical diagnosis and assiduous depiction of imaging findings led to proper therapeutic mapping among clinical entities. In most of cases, especially in surgical controversial issues, use of endoscopic expertise increase potential therapeutic strategy. Neoplasms of the ampulla of Vater are uncommon, with a reported prevalence of 0.04% to 0.12%. Advances in endoscopy during the last 30 years have rendered endoscopic papillectomy (EP) a safe and less invasive therapeutic modality for small, benign periampullary tumors. Aim of our study, consists depiction of our surgical implementation in 5 cases (4 males and 1 female patients) of papillary adenomas accompanied with proper diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: Biliary cannulation failure is a major problem during endoscopic retrograde cholangiopancreatography. It remains unclear how duodenal papilla morphology affects biliary cannulation. Therefore, we proposed a new classification system for the duodenal papilla based on oral protrusion pattern (ratio of the length of the oral protrusion to the transverse diameter of the papilla) and papilla pattern.Aims: To retrospectively compare biliary cannulation results with regard to classification and operator experience.Methods: We analyzed 589 naïve major duodenal papillae. Our classification system comprised oral protrusion pattern, classified as small (Protrusion-S), regular (Protrusion-R), or large (Protrusion-L), and the papilla pattern, classified as annular (Papilla-A), unstructured (Papilla-U), longitudinal (Papilla-LO), isolated (Papilla-I), or gyrus (Papilla-G). Intra-evaluator concordance and the results of biliary cannulation were analyzed.Results: The following oral protrusion pattern classifications were observed: Protrusion-S, 11.7%; Protrusion-R, 77.9%; and Protrusion-L, 10.4%. The following papilla patterns were observed: Papilla-A, 67.1%; Papilla-U, 7.0%; Papilla-LO, 7.5%; Papilla-I, 1.2%; Papilla-G, 15.6%; and unclassified, 1.7%. Intra-evaluator concordance value (Fleiss kappa) was 0.788 for oral protrusion pattern and 0.750 for papilla pattern. A logistic regression analysis of cannulations performed by an experienced endoscopist identified Protrusion-L as a significant risk factor for difficult cannulation (odds ratio 2.956; 95% confidence interval 1.115-7.84; p = 0.029). Multivariate analysis confirmed Protrusion-L as an independent risk factor for difficult biliary cannulation (odds ratio 3.772; 95% confidence interval 1.359-10.464; p = 0.011).Conclusions: We propose a new general classification system for the duodenal papilla. Protrusion-L is a significant risk factor for difficult biliary duct cannulation. [ABSTRACT FROM AUTHOR]

• Ampullary adenocarcinoma is a rare entity during pregnancy. • Diagnosing ampullary adenocarcinoma in pregnancy can be quite challenging, as the symptoms may overlap with the physiological changes of pregnancy. Furthermore, the diagnostic modalities' invasiveness & the associated radiation exposure that might harm the fetus. • The best treatment modality for resectable tumors is in the form of surgery (i.e.; pancreaticoduodenectomy) that is possible during pregnancy. Yet challenging as its important to choose the appropriate time of surgery to insure the viability of the fetus without risking the progression of the disease. • Another challenge that might be encountered is intra-operatively, due to the bulkiness of the uterus which makes such a procedure even more difficult to preform safely & successfully. Ampullary adenocarcinoma is a rare entity during pregnancy. It accounts for 0.5% of all gastrointestinal malignancies. The best treatment modality for resectable tumors with the best reported outcome is surgical resection in the form of pancreaticoduodenectomy (Whipple procedure). In this case report, we discuss the challenges in the management of ampullary adenocarcinoma in a pregnant patient. We report a case of 22 years old pregnant women who presented with vague abdominal pain and jaundice at the 28th week of gestation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture around the ampulla and distal common bile duct (CBD). The CBD was stented and a biopsy was taken. Histopathology revealed: an invasive adenocarcinoma. The patient was managed by elective pancreaticoduodenectomy after induction of vaginal delivery at the 34th week of gestation. Diagnosing and managing ampullary adenocarcinoma in pregnant patients in their 3rd trimester is challenging. Yet, a delayed viable delivery followed by a definitive surgery in the form of pancreaticoduodenectomy offers the best outcomes for both the mother & fetus in case of early stage disease. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the utility of whole-lesion histogram analysis from multidetector computed tomography (MDCT) for discrimination of duodenal adenocarcinoma (DAC), pancreatic ductal adenocarcinoma (PDAC) and gastrointestinal stromal tumor (GIST) around the periampullary area.Materials and Methods: 171 patients suspicious of periampullary tumors were examined by MDCT (arterial and venous phases) and treated with surgery. A total of 74 patients were finally included in this retrospective study (26 DACs, 20 PDACs, and 28 GISTs). The interobserver agreement was evaluated by intra-class correlation coefficient (ICC) test between two radiologists. Volumetric histogram analysis based on CT Kinetics software was performed on enhanced MDCT images that recorded different histogram parameters of arterial and venous phases, including mean, median, 10th, 25th, 75th, and 90th percentiles, as well as skewness, kurtosis and entropy. The extracted histogram parameters were compared between DAC, PDAC and GIST respectively by Mann-Whitney U tests with Bonferroni corrections. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic ability of each significant parameter and the area under the curve (AUC) was calculated.Results: The whole-lesion CT histogram analysis demonstrated significant differences between DAC, PDAC, and GIST with different histogram features on both arterial and venous phase scans (all P < 0.05). In the ROC analysis, the 90th percentile of venous phase demonstrated the highest AUC of 0.854 (P < 0.001) for discriminating DAC from PDAC. Excellent discriminators of periampullary tumors were noted among the histogram features, namely the 90th percentile of arterial phase, which demonstrated AUCs of 0.809 and 0.936 (P < 0.001) respectively for distinguishing DAC and PDAC from GIST.Conclusion: The whole-lesion CT histogram analysis could be useful for differential diagnosis of DAC, PDAC and GIST arising from the periampullary area. Further assessment is warranted to investigate the clinical role of histogram analysis based on MDCT. [ABSTRACT FROM AUTHOR]

Background: Few studies of the oncological outcomes of ampullary cancer have addressed recurrence, and many treatment‐related issues remain unresolved. This study evaluated optimal surgical treatment strategies based on recurrence patterns after pancreaticoduodenectomy (PD) for ampullary cancer. Methods: Two hundred and fifty‐nine patients who underwent PD with R0 resection for ampullary cancer from January 2000 to June 2012 were included. Generally, lymph node (LN) dissection extended to the right superior mesenteric artery (SMA). Recurrence was defined based on imaging studies. The first detected recurrence sites and patterns were analyzed. Results: During a mean follow‐up of 51.3 months, recurrence occurred in 89 (34.4%) cases, most commonly in the liver. Poor differentiation, advanced T stage, and LN metastasis were identified as risk factors for recurrence. Locoregional and systemic recurrences occurred alone or simultaneously in 20.2%, 73.0%, and 6.7% of patients, respectively. Locoregional and systemic recurrences tended to occur in early‐ and advanced‐stage cases, respectively. A nodal‐type recurrence around mesenteric vessels was the most common locoregional recurrence pattern, and 58.8% (10/17) were located left of the SMA. Conclusion: As nodal‐type metastasis around the mesenteric vessels was the dominant recurrence pattern, careful LN dissection around the SMA should be considered for early and advanced ampullary cancers. [ABSTRACT FROM AUTHOR]

Abstract The cell cycle comprises a series of steps necessary for cell growth until cell division. The participation of proteins responsible for cell cycle regulation, known as cyclin dependent kinases or Cdks, is necessary for cycle progression. Cyclin dependent kinase 2 (Cdk-2) is one of the most studied Cdks. This kinase regulates the passage through the G1/S phase and is involved in DNA replication in the S phase. Cdks have been extensively studied in mammals, but there is little information about these proteins in crustaceans. In the present work, the nucleotide and amino acid sequence of Cdk-2 from the white shrimp (Cdk-2) and its expression during hypoxia and reoxygenation are reported. Cdk-2 is a highly conserved protein and contains the serine/threonine catalytic domain, an ATP binding site and the PSTAIRE sequence. The predicted Cdk-2 structure showed the two-lobed structure characteristic of kinases. Expression of Cdk-2 was detected in hepatopancreas, gills and muscle, with hepatopancreas having the highest expression during normoxic conditions. Cdk-2 expression was significantly induced after hypoxia for 24 h in muscle cells, but in hypoxia exposure for 24 followed by 1 h of reoxygenation, the expression levels returned to the levels found in normoxic conditions, suggesting induction of cell cycle progression in muscular cells during hypoxia. No significant changes in expression of Cdk-2 were detected in these conditions in hepatopancreas and gills. Highlights • Shrimp Cdk-2 is a highly conserved protein. • Cdk-2 is expressed during hypoxia and reoxygenation. • Cdk-2 expression and induction in muscle suggest cycle progression during hypoxia and reoxygenation during hypoxia stress. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions.Methods: All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence.Results: We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12-45.9) for ACA, 14.7 months (4.2-34.5) for LSA, and 5.8 months (3.7-22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733).Conclusion: Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered. [ABSTRACT FROM AUTHOR]

Multiple tumors that occur at the same time are defined as synchronized tumors. Occurrence of renal cell carcinomas with synchronous tumors is a rare condition. A 79-year-old female presented with complaints of intermittent fever, anemia, loss of appetite and weight. Imaging studies revealed the presence of pancreatic lesion with proximal choledocal dilatation and a mass lesion in lower pole of the left kidney. The patient was treated successfully by open left partial nephrectomy for the renal cancer and pancreaticoduodenectomy with cholecystectomy for the pancreatic lesion. In this case report, a patient who has synchronous adenocarcinoma of ampulla of Vater and renal cell carcinoma will be presented. [ABSTRACT FROM AUTHOR]

Abstract Acute hepatopancreatic necrosis disease (AHPND) is a bacterial disease of marine shrimp that has caused severe economic losses to aquaculture producers in affected areas. AHPND was originally found to be caused by virulent strains of Vibrio parahaemolyticus (Vp AHPND). These pathogenic strains carry pirAB vp genes, which produce a binary toxin and are located on pVA1-type plasmid. Subsequently, it was found that AHPND can also be caused by pathogenic strains of other Vibrio species including: V. harveyi -like, V. campbellii , V. punensis , and V. owensii , all of which harbor a pVA1-type plasmid. Here we hypothesize that the pVA1-type plasmid can be transferred horizontally among Vibrio species. We carried out laboratory studies confirming the horizontal transfer of pVA1-type plasmid from AHPND-causing V. campbellii strain 20130629003S01 (Vc AHPND -3S01) to a non-AHPND V. owensii strain 20160513VC2W (Vo -VC2W). ANI analysis revealed that strain Vo -VC2W is closely related to the V. owensii strain XSBZ03 isolated from corals in the South China Sea. However, the pirAB vp genes on the transferred plasmid were unstable and lost from the pVA1-type plasmid of Vo -VC2W after 2 sub-culture passages. The sequences of the pVA1-type plasmid in AHPND- Vc 3S01 and Δ pirAB vp Vo -VC2W were highly homologous (99.9% identical), indicating that this plasmid acquired by the V. owensii was from the AHPND- V. campbellii strain. In addition, complete genome sequence of the Δ pirAB vp Vo -VC2W showed that it contains 2 chromosomes and 3 plasmids; its detailed genomic characteristics will provide relevant information for better understanding of a V. owensii isolate that harbors transferred pVA1-type plasmid. [ABSTRACT FROM AUTHOR]

Abstract Acute hepatopancreatic necrosis disease (AHPND) is a shrimp disease caused by a unique strain of Vibrio parahaemolyticus (Vp AHPND). This strain contains a highly pathogenic ~69 kbp (pVA1) plasmid encoding PirA vp and/or PirB vp deadly toxins. The pVA1-like plasmid is also reported to be found in Vibrio harveyi, Vibrio campbellii and Vibrio owensii. Therefore, prompt detection of the bacterial species carrying the PirA vp and/or PirB vp toxins producing genes is essential to control the spread of the disease. In this study, a new 5-plex PCR detection method was developed and optimised to detect Vp AHPND or tetracycline resistant Vp AHPND strain. This technique is designed to include five pairs of primers, which allow a comprehensive PCR diagnostic method for AHPND. The primers flanked five regions which are the Photorhabdus insect-related (Pir) toxin-like genes; pir A vp and pir B vp , thermolabile hemolysin (tlh), housekeeping (tox R) or tetracycline resistance (tet B) genes and also 16S ribosomal RNA (16s rRNA) gene as an internal amplification control (IAC). The detection limit of the 5-plex PCR method is at 10 pg/μl of extracted genomic DNA. Whereas, the specificity of the method analysed using nine Vp AHPND strains, three non-AHPND Vibrio species and ten other bacterial species revealed that the method does not give unspecific reactions with non-AHPND bacteria. The 5-plex PCR method evaluated using three locally isolated Vp AHPND strains and 41 isolates of Vibrio spp. obtained from field samples confirmed that the method developed allows rapid, sensitive and reliable detection of AHPND-causing bacterial strains. The Vp AHPND strains that were detected positive for the tet B gene also showed resistant to tetracycline by disk diffusion antibiotic susceptibility test. The presence of IAC and the primers targeting the tet B gene helps to indicate false-negative results and to detect tetracycline resistant AHPND strains respectively thus differentiating this method from previously reported AHPND PCR methods. Highlights • This manuscript presents a new 5-plex PCR method for Acute hepatopancreatic necrosis disease (AHPND). • The method enables the detection of Vp AHPND or tetracycline resistant Vp AHPND strain in a single PCR reaction. • This method can indicate other bacterial species that carry the pir A vp , pir B vp and tetracycline resistance genes. • The 5-plex PCR for AHPND is proven specific and sensitive to detect at 10 pg/µl of extracted genomic DNA. • The 5-plex PCR method also has been successfully evaluated on field samples. [ABSTRACT FROM AUTHOR]

Introduction. Acute pancreatitis is usually caused by biliary lithiasis and alcohol consumption. Pancreatitis in the elderly is a problem of increasing occurrence. Anatomic abnormalities may represent a less frequent, but important etiological factor. The duodenal diverticula rarely produce signs of inflammation, obstruction, hemorrhage or perforation. In some cases secondary biliary-pancreatic complications are found when a diverticulum originates from the papilla of Vater. Case Report. This case report describes a patient diagnosed with duodenal diverticulum who developed a framework of abdominal pain and laboratory findings compatible with acute pancreatitis which occurred two times in a short period of time. Conclusion. The association of duodenal diverticulum and acute pancreatitis has been reported, but it is important to point out that anatomic abnormalities may represent a less frequent but important etiological factor for acute pancreatitis. [ABSTRACT FROM AUTHOR]

Biliary neuroendocrine neoplasms (NENs) represent <1% of all NENs. The aim of this retrospective study is to present the clinical characteristics, management and prognosis profiles of 28 biliary NEN patients from a large tertiary center, and identify factors related to prognosis. Nine tumors originated from the gallbladder, two from the extrahepatic bile duct and 17 from the ampulla of Vater. One patient was classified as neuroendocrine tumor (NET) Grade 1, three patients were classified as NET Grade 2, 18 were graded neuroendocrine carcinoma (NEC) Grade 3 and six were classified as mixed adenoneuroendocrine carcinoma (MANEC). The overall survival rate and disease-free survival rate did not have statistically significant differences between tumors of different locations or different grading. Recurrence of disease correlated with poor prognosis (p < 0.001). Lymphovascular invasion and invasion beyond the submucosa were related to higher risk of local lymph node metastases. Multivariate analysis identified patient age (p = 0.021) and R0 resection margin (p = 0.027) as independent prognostic factors associated with overall survival. Our study included relatively large numbers of biliary tract NENs with intact follow-up information. Patients with biliary neuroendocrine tumors showed different clinical outcomes according to tumor locations and tumor grades. Achieving R0 resection is important for better prognosis. [ABSTRACT FROM AUTHOR]

Carcinoma of the ampulla of Vater is an uncommon neoplasm and represents 0.5% of all gastrointestinal malignancies, being less common than carcinoma of the pancreas and bile ducts. The most common ampullary tumor is the adenocarcinoma with tubular growth pattern. Signet ring cell carcinoma is extremely rare. In this article, we report a case of signet ring cell carcinoma of the ampulla of Vater showing focal neuroendocrine amphicrine differentiation and intestinal phenotype, which occurred in a 49-year-old male who is still alive 7 years after surgery, without evidence of recurrence. This long-term survival might be attributed not only to the early stage of the disease but also to the neuroendocrine differentiation and the absence of genetic alterations. [ABSTRACT FROM AUTHOR]

We describe the case of a previously healthy 8-year-old girl presenting with a 1-year history of iron deficiency anemia. There was no report of hematemesis, abdominal pain or melena. Laboratory work-up excluded iron malabsorption as the underlying cause. Therefore, endoscopic evaluation was performed to exclude gastrointestinal blood loss, which revealed the presence of a 7 mm reddish lesion located within the ampulla of Vater. Capsule endoscopy excluded alternative diagnoses and concomitant lesions. Histopathological examination confirmed the diagnosis of pyogenic granuloma. The young age of the child and the benign nature of this lesion along with the absence of complications favored conservative management. Pyogenic granuloma is a benign vascular lesion that presents as a polypoid red mass. In the gastrointestinal tract, it is a rare condition and occurs more commonly in the elderly. The most common sites are the small intestine, esophagus, and colon, but they can occur throughout the entire gastrointestinal tract with a propensity to bleed that may cause iron deficiency anemia. In pediatric age patients, there are few reports of gastrointestinal pyogenic granulomas, most of which occur in the colon and rectum. Its identification and location in the ampulla of Vater is an exceptional finding. [ABSTRACT FROM AUTHOR]

Acute hepatopancreatic necrosis disease (AHPND) has caused losses to shrimp farmers worldwide owing to Vibrio parahaemolyticus (VPAHPND). Selective breeding for disease resistance of shrimp was used as an alternative strategy for disease control. Five subsamples of shrimp from 20 full-sib families were subjected to a cohabitation challenge test. Juveniles of P. semisulcatus (mean weight 2.5 ± 0.17 g) were tested for survival after challenge with VPAHPND. Mortality in the challenge test was recorded daily, and the experiment was terminated after 96 days when the mortality ceased. Moderate heritabilities were estimated in resistance to VPAHPND based on a linear model (LM) and threshold model (TM). This indicates that disease resistance is a heritable trait, and a challenge test may serve as a basis for selection for resistance to VPAHPND in P. semisulcatus. However, further investigation is needed to confirm and quantify the additive genetic variation for resistance to VPAHPND in P. semisulcatus. [ABSTRACT FROM AUTHOR]

The field of nanotechnology had enormous developments, resulting in new methods for the controlled synthesis of a wide variety of nanoscale materials with unique properties. Efficient methods such as thermal decomposition for efficient size control have been developed in recent years for the synthesis of oleic acid (OA)-coated magnetite (Fe3O4) nanoparticles (MNP-OA). These nanostructures can be a source of pollution when emitted in the aquatic environment and could be accumulated by vulnerable marine species such as crustaceans. In this work, we synthesized and characterized MNP-OA of three different diameters (5, 8, and 12 nm) by thermal decomposition. These nanoparticles were remarkably stable after treatment with high affinity iron chelators (calcein, fluorescent desferrioxamine, and fluorescent apotransferrin); however, they displayed pro-oxidant activity after being challenged with ascorbate under two physiological buffers. Free or nanoparticle iron displayed low toxicity to four types of hepatopancreatic cells (E, R, F, and B) of the mangrove crab Ucides cordatus; however, they were promptly bioavailable, posing the risk of ecosystem disruption due to the release of excess nutrients. [ABSTRACT FROM AUTHOR]

Objective: The aim of the research was to study adenomatous and adenomyomatous lesions of the major duodenum papilla with its normal structure and the presence of heterotopic pancreatic tissue in it. Materials and Method: The study was carried out on the material of 327 pathoanatomical autopsies taking into account the sex, age, clinical data, pathoanatomical, and clinical diagnoses. The material is divided into two groups: The 1st group - without an ectopic pancreatic tissue in the major duodenum papilla (279 cases) and the 2nd group - with different variants of ectopic pancreatic tissue (48 cases). In each of them, the distribution was carried out according to sex, age, and cause of death. Results: Adenomyomatous lesions of the papilla of Vater often combined with pancreatic heterotopia in it - in 23 of 48 cases, various changes were observed in both the papilla wall and ectopic tissue. These include atrophy of the epithelial structures of the papilla, primarily glands, hyperplastic changes in the mucous membrane and glands, significant ductal and cystic transformation, and foci of adenomyosis. Conclusion: In the areas of hyperplastic changes in the epithelium of the cystically altered ducts, hyperplasia of stromal elements with a smooth-muscle immunophenotype was determined. [ABSTRACT FROM AUTHOR]

While toxin-harboring Vibrio parahaemolyticus has been previously established as the causative agent of early mortality syndrome (EMS) or acute hepatopancreatic necrosis disease (AHPND) in shrimp, information on the mechanistic processes that happen in the host during infection is still lacking. Here, we examined the expression responses of the shrimp hemocyte transcriptome to V. parahaemolyticus AHPND (VP AHPND ) by RNA sequencing (RNA-seq). Using libraries (SRA accession number SRP137285) prepared from shrimp hemocytes under experimental conditions, a reference library was de novo assembled for gene expression analysis of VP AHPND -challenged samples at 0, 3/6, and 48 h post infection (hpi). Using the library from 0-hpi as the control, 359 transcripts were found to be differentially expressed in the 3/6-hpi library, while 429 were differentially expressed in the 48-hpi library. The expression patterns reported in the RNA-seq of 9 representative genes such as anti-lipopolysaccharide factor ( Lv ALF), crustin p (CRU), serpin 3 (SER), C-type lectin 3 (CTL), clottable protein 2 (CLO), mitogen-activated protein kinase kinase 4 (MKK4), P38 mitogen-activated protein kinase (P38), protein kinase A regulatory subunit 1 (PKA) and DNAJ homolog subfamily C member 1-like (DNJ) were validated by qRT-PCR. The expression of these genes was also analyzed in shrimp that were injected with the partially purified VP AHPND toxin. A VP AHPND toxin-responsive gene, Lv ALF was identified, and its function was characterized by RNA interference. Lv ALF knockdown resulted in significantly rapid increase of shrimp mortality caused by toxin injection. Protein-protein interaction analysis by molecular docking suggested that Lv ALF possibly neutralizes VP AHPND toxin through its LPS-binding domain. The data generated in this study provide preliminary insights into the differences in the immune response of shrimp to the bacterial and toxic aspect of VP AHPND as a disease. [ABSTRACT FROM AUTHOR]

Adenomyoma and adenomyomatous hyperplasia are benign tumor-like lesions that rarely involve the major or minor duodenal papilla. We report the case of a 73-year-old patient who underwent a cephalic duodenopancreatectomy due to clinical and radiological evidence of underlying malignant neoplasm. The histopathology results revealed the unusual association of a major duodenal papilla adenomyoma and an adenomyomatous hyperplasia of the minor papilla. Because of their resemblance to pancreatic malignancy, the diagnosis of these lesions is particularly challenging. In most cases, it is established postoperatively, after histopathological examination of the surgical specimen. [ABSTRACT FROM AUTHOR]

Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8–81.4%, I2 = 91.38%) for EA, 96.4% (93.6–99.2%, I2 = 37.8%) for SA and 98.9% (98.0–99.7%, I2 = 0%) for PD. AEs were 24.7% (19.8–29.6%, I2 = 86.4%), 28.3% (19.0–37.7%, I2 = 76.8%) and 44.7% (37.9–51.4%, I2 = 0%), respectively. Recurrences were registered in 13.0% (10.2–15.6%, I2 = 91.3%), 9.4% (4.8–14%, I2 = 57.3%) and 14.2% (9.5–18.9%, I2 = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

Several studies have compared laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with periampullary carcinoma; however, only a few studies have made such a comparison on patients with ampulla of Vater cancer (AVC). We compared the perioperative and oncologic outcomes between LPD and OPD in patients with AVC using propensity-score-matched analysis. A total of 359 patients underwent PD due to AVC during the study period (76 LPD, 283 OPD). After propensity score matching, the LPD group showed significantly longer operation time than did the OPD group (400.2 vs. 344.6 min, p < 0.001). Nevertheless, the LPD group had fewer painkiller administrations (8.3 vs. 11.1, p < 0.049), fewer Grade II or more severe postoperative complications (15.9% vs. 34.8%, p = 0.012), and shorter postoperative hospital stays (13.7 vs. 17.3 days, p = 0.048), compared with the OPD group. There was no significant difference in recurrence-free outcomes and overall survival between the two groups (p = 0.754 and 0.768, respectively). Compared with OPD, LPD for AVC had comparative oncologic outcomes with less pain, less postoperative morbidity, and shorter hospital stays. LPD may serve as a promising alternative to OPD in patients with AVC.

ABSTRACT Introduction: Periampular neoplasms represent 5% of all cancers of the gastrointestinal tract with peak incidence in the 7th decade of life. The most common clinical picture is jaundice, weight loss and abdominal pain. Considering that cholestasis is related to postoperative complications, preoperative biliary drainage was developed to improve the postoperative morbidity and mortality of icteric patients with periampular neoplasias, whether resectable or not. Objective: To describe the outcome of patients with periampullary tumors undergoing preoperative biliary drainage with pancreatoduodenectomy. Method: The search was performed in the Medline/PubMed and Virtual Health Library databases by means of the combination of descriptors of the Medical Subject Headings. Inclusion criteria were clinical trials, cohorts, studies that analyze the morbidity and mortality of preoperative biliary drainage in Portuguese, English and Spanish. Exclusion criteria were studies published more than 10 years ago, experimental studies, systematic reviews and articles with WebQualis C or smaller journal in the area of Medicine I or Medicine III. Of the 196 references found, 46 were obtained for reading with quality assessed through the Checklist Strengthening the Reporting of Observational Studies in Epidemiology. Eight studies were selected for review. Results: A total of 1116 patients with a sample ranging from 48 to 280 patients and a mean age of 48 to 69 years were obtained. Of the eight studies, four observed a higher rate of bleeding in drained patients; three a higher rate of positive bile culture in the intervention group; site and cavitary infection, and biliopancreatic leaks were more common in the drainage group in two studies each. The death outcome and rate of reoperation were observed in larger numbers in the control group in one study each. Conclusion: Preoperative intervention leads to a higher rate of infectious complications and bleeding.