Primary pancreatic lymphoma:A case report and review of literature

BACKGROUND Primary pancreatic lymphoma(PPL)is a rare tumor that mimics pancreatic adenocarcinoma,leading to diagnostic and therapeutic challenges.PPL accounts for 0.2%of all pancreatic tumors and is typically treated with chemotherapy.However,the long-term survival rates for PPL with chemotherapy and radiotherapy alone are unsatisfactory.Due to the improvements in pancreatic surgery,there is a need to reevaluate the treatment strategies for PPL.CASE SUMMARY A 62-year-old male presented to our clinic.A biopsy was unsuccessful,and the imaging was suggestive of pancreatic adenocarcinoma.Therefore,subtotal splenopancreatectomy was performed and histopathology was performed.He was then diagnosed with primary pancreatic diffuse large B-cell lymphoma.He received adjuvant chemotherapy and radiotherapy.Currently,the patient is alive with no evidence of disease 36 months after surgery.CONCLUSION The potential role of surgery in the treatment of PPL should be emphasized and added in the management protocol of early stage lymphoma.

Limited resection for duodenal gastrointestinal stromal tumors:Surgical management and clinical outcome

AIM:To analyze our experience in patients with duodenal gastrointestinal stromal tumors(GIST) and review the appropriate surgical approach.METHODS:We retrospectively reviewed the medical records of all patients with duodenal GIST surgically treated at our medical institution between 2002 and 2011.Patient files,operative reports,radiological charts and pathology were analyzed.For surgical therapy open and laparoscopic wedge resections and segmental resections were performed for limited resection(LR).For extended resection pancreatoduodenectomy was performed.Age,gender,clinical symptoms of the tumor,anatomical localization,tumor size,mitotic count,type of resection resectional status,neoadjuvant therapy,adjuvant therapy,risk classification and follow-up details were investigated in this retrospective study.RESULTS:Nine patients(5 males/4 females) with a median age of 58 years were surgically treated.The median follow-up period was 45 mo(range 6-111 mo).The initial symptom in 6 of 9 patients was gastrointestinal bleeding(67%).Tumors were found in all four parts of the duodenum,but were predominantly located in the first and second part of the duodenum with each 3 of 9 patients(33%).Two patients received neoadjuvant medical treatment with 400 mg imatinib per day for 12 wk before resection.In one patient,the GIST resection was done by pancreatoduodenectomy.The 8 LRs included a segmental resection of pars 4 of the duodenum,5 wedge resections with primary closure and a wedge resection with luminal closure by Roux-Y duodeno-jejunostomy.One of these LRs was done minimally invasive;seven were done in open fashion.The median diameter of the tumors was 54 mm(14-110 mm).Using the Fletcher classification scheme,3/9(33%) tumors had high risk,1/9(11%) had intermediate risk,4/9(44%) had low risk,and 1/9(11%) had very low risk for aggressive behaviour.Seven resections showed microscopically negative transsection margins(R0),two showed positive margins(R1).No patient developed local recurrence during follow-up.The one patient who underwent pancreatoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence.Another patient died in complete remission due to cardiac disease.Seven of the nine patients are alive disease-free.CONCLUSION:In patients with duodenal GIST,limited surgical resection with microscopically negative margins,but also with microscopically positive margins,lead to very good local and systemic disease-free survival.

Impact of remote ischemic preconditioning on wound healing in small bowel anastomoses

AIM： To investigate the influence of remote ischemic preconditioning （RIPC） on anastomotic integrity. METHODS： Sixty male Wistar rats were randomized to six groups. The control group （n = 10） had an end- to-end ileal anastomosis without RIPC. The preconditioned groups （n = 34） varied in time of ischemia and time of reperfusion. One group received the amino acid L-arginine before constructing the anastomosis （n = 9）. On postoperative day 4, the rats were re-laparotomized, and bursting pressure, hydroxyproline concentration, intra-abdominal adhesions, and a histological score concerning the mucosat ischemic injury were collected. The data are given as median （range）.RESULTS： On postoperative day 4, median bursting pressure was 124 mmHg （60-146 mmHg） in the control group. The experimental groups did not show a statistically significant difference （P 〉 0.05）. Regarding the hydroxyproline concentration, we did not find any significant variation in the experimental groups. We detected significantly less mucosal injury in the RIPC groups. Furthermore, we assessed more extensive intra-abdominal adhesions in the preconditioned groups than in the control group. CONCLUSION： RIPC directly before performing small bowel anastomosis does not affect anastomotic stability in the early period, as seen in ischemic preconditioning.

Extracellular matrices for gastrointestinal surgery:Ex vivo testing and current applications

AIM:To assess the effects of bile and pancreatic juice on structural and mechanical resistance of extracellular matrices(ECMs) in vitro.METHODS:Small-intestinal submucosa(SIS),porcine dermal matrix(PDM),porcine pericardial matrix(PPM) and bovine pericardial matrix(BPM) were incubated in human bile and pancreatic juice in vitro.ECMs were examined by macroscopic observation,scanning electron microscopy(SEM) and testing of mechanical resistance.RESULTS:PDM dissolved within 4 d after exposure to bile or pancreatic juice.SIS,PPM and PDM retained their integrity for > 60 d when incubated in either digestive juice.The effect of bile was found to be far more detrimental to mechanical stability than pancreatic juice in all tested materials.In SIS,the loss of mechanical stability after incubation in either of the digestive secretions was less distinct than in PPM and BPM [mFmax 4.01/14.27 N(SIS) vs 2.08/5.23 N(PPM) vs 1.48/7.89 N(BPM)].In SIS,the extent of structural damage revealed by SEM was more evident in bile than in pancreatic juice.In PPM and BPM,structural damage was comparable in both media.CONCLUSION:PDM is less suitable for support of gastrointestinal healing.Besides SIS,PPM and BPM should also be evaluated experimentally for gastrointestinal indications.

A Novel Rodent Model Modifying Perioperative Temperature and Humidity during Bowel Surgery and Mimicking Laparoscopic Conditions

Laparoscopic surgery seems to have a general physiological benefit compared to conventional procedures in several clincal studies especially regarding intestinal anastomotic healing. Reliable experimental data concerning the particular mode of beneficial action are lacking. Clinical studies will not be able to identify the variables responsible for this effect. To establish a feasible, standardized experimental model to investigate variables such as humidity and perioperative room temperature, we employed an incubator designed for neonatal care. This allows individual manipulation and observation of above mentioned variables. Our initial results show that creating intestinal anastomoses in the incubator is safe and easy to perform, creating a valuable possibility to influence perioperative conditions for experimental and clinical research.