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Context Endoscopic ultrasonography (EUS) can show pancreatic tumors of few millimeters; nowadays, in the years of laparoscopic approach, the most difficult and time-consuming issue can be how to identify a tumor throughout the pancreatic parenchyma in order to select the site where to transect the pancreas. Preoperative EUS-tattooing could be of help in locating small pancreatic tumors during pancreatic resections. Case report Because of the onset of recurrent mild abdominal pain and diarrhea lasting for 4 months, a 70-year-old woman performed a trans-abdominal US that showed a hypoecogenic area of about 7 mm in the body of the pancreas. She had no other significant medical history or laboratory index. A CT-scan did not reveal any lesion throughout the pancreas. EUS examination (using a linear echoendoscope Fujinon) confirmed a hypoecogenic, solid, irregular mass of the body of the pancreas of about 7x4 mm. An EUS-guided fine-needle aspiration biopsy of the lesion was performed with a 22-gauge ProCore needle (Cook) and then, EUS-guided tattoo was performed using a 22 gauge EchoTip needle: the needle was inserted 3-5 mm proximal to the lesion and 2 mL of sterile purified carbon particles were injected under direct visualization. The patient received pre-procedural i.v. ciprofloxacin and no complications were observed. Cytological examination reported cells suspicious for adenocarcinoma. Nineteen days later, the patient underwent a laparoscopic left pancreatectomy. Ink was clearly visible on the anterior surface of the pancreas. Operative time was 110 minutes. Postoperative outcome was uneventful. Pathologic evaluation revealed a ductal adenocarcinoma of 5 mm in diameter with 17 negative nodes. Distance between pancreatic resection margin and cancer was 15 mm. Conclusions Preoperative EUS-tattooing could facilitate laparoscopic localization of small lesions. Further studies to assess safety, indications and limits are needed., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Studies on kinetics of metastases revealed that pancreatic cancer should be considered a systemic disease at the time of diagnosis, regardless of tumor stage at imaging. Surgery is generally not indicated for metastatic pancreatic cancer because it is supposed not to improve survival. Objective Is metastasis from periampullary cancer an absolute contraindication to surgery? Could someone benefit from liver resection? Who? Methods Our prospectively collected database (2003-2012) lists 20 patients who underwent liver resection for metastases from periampullary, non-endocrine cancer. Generally, resection was offered in young patient, fit for surgery, with few metastases. Fourteen patients were affected by synchronous metastases and they underwent simultaneous pancreatectomy and liver resection, 6 patients experienced metachronous metastases. Results Median age was 60 years (IQR: 52-65 years). Pancreatic ductal carcinoma was the primary tumor in 15 patients, the remaining patients were affected by ampullary carcinoma or distal bile duct carcinoma. One right hepatectomy, 2 bisegmentectomies and 17 atypical resections were performed. Simultaneous liver and pancreatic resections did not improve postoperative morbidity and mortality if compared to standard pancreatic resections. Median follow-up was 47 months. Median overall survival (OS) was 15 months (95%CI: 8-22 months). Median OS in patients with synchronous metastases was 12 months (95%CI: 7-17 months). Median OS in patients with metachronous metastases was 28 months (95%CI: 2-55 months) from liver resection, 38 months from pancreatectomy. Conclusion Surgery for liver metastases from periampullary tumors is a minefield. It is a wrong step for most patients and death may occur even earlier if compared to palliative cure. However, a small group of patients could benefit from surgery and find a path to long-term survival., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650