Search

Resume Introduction Les cancers du pancreas et de la region peri-ampullaire chez les patients âges de plus de 80 ans posent encore des problemes aux chirurgiens a cause du risque de la chirurgie sur ce terrain. Nous avons revu notre experience et celle rapportee dans la litterature des pancreatectomies chez les patients octogenaires, afin d’evaluer les resultats precoces et la survie a long terme en cas de cancer. Methode Trois cent quatre-vingt-cinq patients ayant eu une pancreatectomie pour tumeur entre 1998 et 2011 etaient inclus dans l’etude et ont ete divises en deux groupes : le groupe 1 forme de patients âges de moins de 80 ans ; et le groupe 2 de patients âges de 80 ans et plus. La morbidite, la mortalite perioperatoires, la survie sans recidive et la survie a long terme etaient analysees. Une recherche bibliographique etait faite sur les resultats des resections pancreatiques chez les patients octogenaires. Resultats Parmi les 385 patients : 362 etaient dans le groupe 1 et 23 dans le groupe 2. Il n’y avait pas de differences significatives pour le sexe et les caracteristiques tumorales entre les deux groupes. Le taux de complications (40 vs 43 %) et de mortalite (4 vs 0 %) et la survie globale mediane pour les cas de cancer du pancreas (21 vs 19 mois) n’etaient pas significativement differentes entre le groupe 1 et le groupe 2. La revue de la litterature a retrouve 14 etudes dont la plupart des etudes (surtout celles provenant de centre a gros volume) montraient des resultats similaires entre les patients octogenaires et les patients plus jeunes. Conclusion La pancreatectomie est une option acceptable chez les patients âges. L’âge seul ne peut etre considere comme une contre-indication a la resection pancreatique, mais une evaluation rigoureuse avant l’intervention et une prise en charge perioperatoire optimale sont essentielles.

Summary Introduction Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group. Methods Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80 years of age, and group 2, patients 80 years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians. Results There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications’ rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19 months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients. Conclusion Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory.

Abdominal actinomycosis is an uncommon subacute or chronic inflammatory disease due to a filamentous, gram-positive, anaerobic bacterium: Actinomyces israelii. The pathogen invades surrounding tissues, spreads by contiguity causing a suppurative and granulomatous inflammation with formation of abscess. Case report: A 66-year-old asymptomatic woman with incidentally radiological finding of a pancreatic head solid mass. Approximately 35 years before, she underwent cholecystectomy and choledocotomy for gallstones of the biliary tract. Suspecting of a neuroendocrine tumor, the patient was enrolled to pancreaticoduodenectomy. Histologic examination revealed pancreatic actinomycosis. Foci of severe dysplasia of the pancreatic ductal epithelium were found, and bacteria referable to Actinomyces were isolated. Pancreatic actinomycosis is extremely rare but it should be considered in the differential diagnosis with other pancreatic disease. In the literature, it was been reported that the abdominal location could be related to contamination by gallstone spillage during biliary surgery. Prognosis is excellent if actinomycosis is well treated; early diagnosis is mandatory but remains a challenge, and often is achieved only after surgery.

AIM To analyze the importance of para-aortic node status in a series of patients who underwent pancreaticoduodenectomy (PD) in a single Institution. METHODS Between January 2000 and December 2012, 151 patients underwent PD with para-aortic node dissection for pancreatic adenocarcinoma in our Institution. Patients were divided into two groups: patients with negative PALNs (PALNs-), and patients with metastatic PALNs (PALNs+). Pathologic factors, including stage, nodal status, number of positive nodes and lymph node ratio, invasion of para-aortic nodes, tumor’s grading, and radicality of resection were studied by univariate and multivariate analysis. Survival curves were constructed with Kaplan-Meier method and compared with Log-rank test: significance was considered as P < 0.05. RESULTS A total of 107 patients (74%) had nodal metastases. Median number of pathologically assessed lymph nodes was 26 (range 14-63). Twenty-five patients (16.5%) had para-aortic lymph node involvement. Thirty-three patients (23%) underwent R1 pancreatic resection. One-hundred forty-one patients recurred and died for tumor recurrence, one is alive with recurrence, and 9 are alive and free of disease. Overall survival was significantly influenced by grading (P = 0.0001), radicality of resection (P = 0.001), stage (P = 0.03), lymph node status (P = 0.04), para-aortic nodes metastases (P = 0.02). Multivariate analysis showed that grading was an independent prognostic factor for overall survival (P = 0.0001), while grading (P = 0.0001) and radicality of resection (P = 0.01) were prognostic parameters for disease-free survival. Number of metastatic nodes, node ratio, and para-aortic nodes involvement were not independent predictors of disease-free and overall survival. CONCLUSION In this experience, lymph node status and para-aortic node metastases were associated with poor survival at univariate analysis, but they were not independent prognostic factors.

Aim of this study was to review the institutional experience of solid-pseudopapillary tumors of the pancreas with particular attention to the problems of preoperative diagnosis and treatment. From 1997 to 2013, SPT was diagnosed in 18 patients among 451 pancreatic cystic neoplasms (3.7%). All patients underwent preoperative abdominal ultrasound, computed assisted tomography, and tumor markers (CEA and CA 19-9) determinations. In some instances, magnetic resonance, positron emission tomography, and endoscopic ultrasound with aspiration cytology were performed. There were two males and 16 females. Serum CA 19-9 was slightly elevated in one case. Preoperative diagnosis was neuroendocrine tumor (n=2), mucinous tumor (n=2), and SPT (n=14). Two patients underwent previous operation before referral to our department: one explorative laparotomy and one enucleation of SPT resulting in surgical margins involvement. All patients underwent pancreatic resection associated with portal vein resection (n=1) or liver metastases (n=1). One patient died of metastatic disease, 77 months after operation, and 17 are alive and free with a median survival time of 81.5 months (range 36–228 months). Most of SPT can be diagnosed by CT or MRI, and the role of other diagnostic tools is very limited. We lack sufficient information regarding clinicopathologic features predicting prognosis. Caution is needed when performing limited resection, and long and careful follow-up is required for all patients after surgery.

Primary leiomyosarcoma is a rare malignant neoplasm, although it is the most common primary pancreatic sarcoma [1]. It accounts for 0.1 % of malignant pancreatic neoplasms [2], and it seems to arise from smooth muscle cells of ducts or blood vessels within the pancreas [3] Pancreatic leiomyosarcoma is a highly aggressive neoplasm in which widespread metastases occur frequently and the liver is typically affected [4], so the prognosis is generally bad [5]. Radical resection of the primary lesion seems to offer the best possibility for cure [6]. We report a case of primary leiomyosarcoma of the pancreas with synchronous hepatic metastases occurring in a 54-year-old female who was treated with repeated surgical excision together with different chemotherapeutic regimens.

Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis.

No abstract available, JOP. Journal of the Pancreas, Vol 14, No 6 (2013): November - p. 603-693

Background The incidence of pancreatic cancer is increasing, and an increasing proportion of patients with pancreatic carcinoma is older than 75 years. After surgical resection remains the treatment of choice for pancreatic neoplasms, an increasing number of elderly patients are being referred for pancreatic resection. Although in the early 1990s there was rarely an indication for major pancreatic resection in the elderly because of the high postoperative complication rate, mortality and limited survival time [1], more recently an acceptable morbidity rate and late outcome in patients with advanced age have been reported [2,3]. This retrospective study analyzed the effect of age on the survival of patients who underwent resection for pancreatic cancer.

Pancreatic metastasis from several malignancies are increasingly encountered in clinical practice, and the usefulness of surgical resection has been suggested for certain neoplasms. Isolated pancreatic metastasis from malignant melanoma is a rare occurrence, and the role of surgery as an adjunct to systemic therapy for melanoma metastatic to a solitary or multiple sites is still debated.We report a patient with melanoma of unknown primary site metastatic simultaneously to the lung and pancreas 3 years after axillary lymph node dissection. Distal pancreatectomy with splenectomy and video thoracoscopic assisted resection of pulmonary metastasis were performed. The postoperative course was uneventful, but 6 months after surgery, the patient experienced single pulmonary recurrence. During chemotherapy with different drugs, pulmonary lesion remained stable for 1 year, and no abdominal recurrence occurred. After then, the size of the lesion progressively increased and a second metastasis occurred in the lung. Five months later, brain metastases occurred, and the patients died 24 months after surgery. Sixteen pancreatic resections for metastatic malignant melanoma, reported with adequate clinical details, were also retrieved from the literature.In spite of the very limited experience, it appears that surgical resection is only a palliative procedure, because long-term survival is a rare event. However, considering the lack of effective systemic therapy, surgery may be considered as a part of an aggressive multidisciplinary approach in selected cases with malignant melanoma metastatic to single or multiple visceral sites.

Context Total pancreatectomy is the treatment of choice for multicentric diseases involving the head and the body-tail of the pancreas. Middle-preserving pancreatectomy is a recently reported alternative procedure when the pancreatic body is spared from disease. We report on the successful preservation of the pancreatic body in a patient harboring a multicentric intraductal papillary mucinous neoplasia (IPMN). Case report A multicentric IPMN was diagnosed in a 59-year-old man. A standard pylorus preserving pancreaticoduodenectomy was performed, followed by a spleen-preserving distal pancreatectomy. The splenic vessels were carefully preserved. The residual 5 cm of the pancreatic body were anastomosed to the jejunum after verifying that the resection line on both sides was negative at frozen section examination. The postoperative course was complicated by transient peritoneal bleeding managed with angiographic embolization of the splenic artery. A borderline mixed type IPMN of the head and chronic pancreatitis of the tail were found at pathological examination. Eleven months after surgery, the patient is well and disease free; glycemic control is achieved by diet. Conclusion A middle-preserving pancreatectomy can be performed safely for multicentric IPMNs involving the head and the body-tail of the gland. It can prevent problems with the glycemic control that usually follows total pancreatectomy. Image: The end result of middle-preserving pancreatectomy with double jejunal loop reconstruction., JOP. Journal of the Pancreas, Vol 11, No 3 (2010): May - p. 199-298

increased by more than $10,000 with each severity grade of ISGPS DGE (p

Background Skeletal muscle is the major reservoir of body proteins and it can be affected in conditions associated to altered protein turnover and metabolism such as cancer. Although severe wasting is seen primarily in patients with advanced malignancy, some of them present degree of wasting at the onset of disease. Autophagy has been recently described to play a relevant role inmuscle wasting.Materials andMethodsWeperformedmorphometric studies and immunohistochemical analyses on intraoperative rectus abdominis muscle biopsies from 50 consecutive weight stable colorectal patients and 25 weight-stable patients operated for non-inflammatory benign diseases with no clinical signs of myopathies. Biochemical and molecular analyses have been performed in order to evaluate protein profile, the presence of autophagy induction and their correlation with clinical outcome. Results In cancer patients, we observed a subclinical myopathy characterized by an abnormal distribution of myonuclei relocated from the periphery inside themyofiber. The percentage ofmyofibers with abnormally located myonuclei was significantly higher in patients (median= 9%) compared to controls (median= 2.7%) (p=0.0002). Analyses on serum samples showed that, in the absence of systemic inflammation, in the prevalence of cancer patients the levels of albumin and prealbumin were below the normal range and the mean value was significantly lower compared to that detected in controls (albumin: 34.82 ± 5.8 g/L vs 45.2 ± 5.3, p< 0.01; prealbumin: 174.38±57.86 mg/L vs 264.00±69.73, p

Primary extra-gastrointestinal stromal tumor (EGISTs) arising in the pancreas is extremely rare: only 20 cases have previously been reported in the English literature from 2000 to 2013. We reported a case of EGIST of the pancreas in a 69-year-old woman who presented with abdominal pain and with a solid, heterogeneously enhancing neoplasm in the uncinate process of the pancreas, revealed preoperatively by an abdominal computed tomography scan. A diagnosis of neuroendocrine tumor was suggested. Positron emission tomography with 68Ga-DOTATOC did not show pathological accumulation of the tracer in the pancreas. The patient underwent enucleation, under ultrasonic guidance, of the pancreatic tumor that emerged to the surface of the pancreas. Histopathology and immunohistochemical examination confirmed the final diagnosis of EGIST of the pancreas (CD117+), with one mitosis per 50 high-power fields. Although rarely, GIST can involve the pancreas as a primary site, and this tumor should be considered in the differential diagnosis of pancreatic neoplasms.

Clinical background The increasing aging of the Western population is obviously accomplished by an increasing number of older patients with cancer, including pancreatic cancer. Since surgical resection remains the treatment of choice for pancreatic and periampullary neoplasms, increasing number of elderly patients are being referred for pancreatic resection. Recently, some surgical experiences reported an acceptable morbidity rate and outcome in patients with advanced age. This retrospective study analyzes the effects of age on short-term and long-term outcome in a large series of patients who underwent resection for pancreatic or periampullary disease.