Value of three-dimensional reconstructions in pancreatic carcinoma using multidetector CT:Initial results

AIM:To evaluate the use of three-dimensional imaging of pancreatic carcinoma using multidetector computed tomography(CT)in a prospective study.METHODS:Ten patients with suspected pancreatic tumors were examined prospectively using multidetec-tor CT(Somatom Sensation 16,Siemens,Erlangen,Germany).The images were evaluated for the pres-ence of a pancreatic carcinoma and invasion of the peripancreatic vessels and surrounding organs.Using the isotropic CT data sets,a three-dimensional image was created with automatic vascular analysis and semi-automatic segmentation of the organs and pancreatic tumor by a radiologist.The CT examinations and the three-dimensional images were presented to the sur-geon directly before and during the patient's operation using the Medical Imaging Interaction Toolkit-based software "ReLiver".Immediately after surgery,the value of the two images was judged by the surgeon.The operation and the histological results served as the gold standard.RESULTS:Nine patients had a pancreatic carcinoma(all pT3),and one patient had a serous cystadenoma.One tumor inf iltrated the superior mesenteric vein.The inf iltration was correctly evaluated.All carcinomas were resectable.In comparison to the CT image with axial and coronal reconstructions,the three-dimensional image was judged by the surgeons as better for operation planning and consistently described as useful.CONCLUSION:A 3D-image of the pancreas repre-sents an invaluable aid to the surgeon.However,the 3D-software must be further developed in order to be integrated into daily clinical routine.

CT diagnosis of recurrence after pancreatic cancer:Is there a pattern?

AIM:To investigate predilection sites of recurrence of pancreatic cancer by computed tomography(CT)in follow-up after surgery. METHODS:Seventy seven patients with recurrence after pancreatic cancer surgery were retrospectively identified.The operative technique,R-status,T-stage and development of tumor markers were evaluated. Two radiologists analyzed CT scans with consensus readings.Location of local recurrence,lymph node recurrence and organ metastases were noted.Surgery and progression of findings on follow-up CT were con-sidered as reference standard. RESULTS:The mean follow-up interval was 3.9± 1.8 mo,with a mean relapse-free interval of 12.9± 10.4 mo.The predominant site of recurrence was local (65%),followed by lymph node(17%),liver metastasis (11%)and peritoneal carcinosis(7%).Local recurrence emerged at the superior mesenteric artery(n=28),the hepatic artery(n=8),in an area defined by the surrounding vessels:celiac trunk,portal vein,inferior vena cava(n=22),and in a space limited by the mesenteric artery,portal vein and inferior vena cava(n=17). Lymph node recurrence occurred in the mesenteric root and left lateral to the aorta.Recurrence was confirmed by surgery(n=22)and follow-up CT(n=55).Tumor markers[carbohydrate antigen 19-9(CA19-9),carcinoembryonic antigen(CEA)]increased in accordance with signs of recurrence in most cases(86%CA19-9;79.2% CEA). CONCLUSION:Specific changes of local and lymph node recurrence can be found in the course of the cardinal peripancreatic vessels.The superior mesenteric artery is the leading structure for recurrence.

Noninvasive indocyanine green plasma disappearance rate predicts early complications,graft failure or death after liver transplantation

BACKGROUND:Early detection of graft malfunction or postoperative complications is essential to save patients and organs after orthotopic liver transplantation (OLT).Predictive tests for graft dysfunction are needed to enable earlier implementation of organ-saving interventions following transplantation.This study was undertaken to assess the value of indocyanine green plasma disappearance rates (ICG-PDRs) for predicting postoperative complications,graft dysfunction and patient survival following OLT.METHODS:Eighty-six patients undergoing OLT were included in this single-centre trial.ICG-PDR was assessed daily for the first 7 days following OLT.Endpoints were graft loss or death within 30 days and postoperative complications,graft loss,or death within 30 days.RESULTS:Postoperative complications of 31 patients included deaths (12 patients) or graft losses.ICG-PDR was significantly different in patients whose endpoints were graft loss or death beginning from day 3 and in those whose endpoints were graft loss,death,or postoperative complications beginning from day 4 after OLT.For day 7 measurements,receiver operating characteristic curve analysis revealed an ICG-PDR cut-off for predicting death or graft loss of 9.6% per min (a sensitivity of 75.0%,a specificity of 72.6%,positive predictive value 0.35 negative predictive value 0.94).For prediction of graft loss,death or postoperative complications,the ICG-PDR cut-off was 12.3%per min (a sensitivity of 68.9%,a specificity of 66.7%,positive predictive value 0.57,negative predictive value 0.77).CONCLUSIONS:ICG-PDR measurements on postoperative day 7 are predictive of early patient outcomes following OLT.The added value over that of routinely determined laboratory parameters is low.

胰腺癌外科

胰腺癌是人类最有侵犯性的实体肿瘤之一,其治疗仍然面临挑战,切除术是唯一的潜在性治愈方法 ,切除后的5年生存率大约为25%.在过去的数十年,由于手术技术和围手术期管理的发展,胰腺外科已经有了翻天覆地的变化.经典的whipple术式于上世纪70年代被修改,提出保留幽门,这种改良被广泛接受.除外胰头和十二指肠切除,应提出一个标准化的淋巴结清扫术,这包括切除肝十二指肠韧带,清扫沿肝总动脉,门静脉,肠系膜上静脉头盖部分,腹腔干右侧,沿肠系膜上动脉右侧淋巴结.更大范围的淋巴结清扫术没有意义.切除一旦完成,术中冰冻切片送检,以确保剩余胰腺和胆管切缘无瘤组织.胰十二指肠切除术后重建中至关重要的一步是胰肠吻合术,我们开展了一种端侧双层胰管空肠缝合技术,使胰瘘率低于3.5%.胆管重建也应标准化.长期生存率表明门静脉或肠系膜上静脉切除具有潜在治愈性.辅助治疗可以提高生存期.作为对比,肿瘤浸润肠系膜上动脉,腹腔干或肝动脉是胰腺癌不能切除的标准,这一观念已被接受.但是,动脉肿瘤粘附并不意味着已经浸润,因动脉壁较静脉壁更有保护性.最近的一份回顾分析报道,在联合门静脉或肠系膜上静脉切除的胰腺手术中,15%同步实施动脉切除,尽管他们的肿瘤学价值有待商榷.远端胰腺切除后胰瘘仍然是我们所要面临的问题,我们自2009年2月,开展了一项由21个欧洲机构参与,360例患者组成的多中心随机对照研究,以比较锐性切除后残端缝合封闭与订书机式切除.在良性胰腺疾病或IPMN中,若脾脏血管未被累及,可实施脾脏保留的远端胰腺切除术.有不断积累的证据表明腔镜下行远端胰腺切除有良好的效果.根据肿瘤学观点,广泛的主胰管IPMN,有癌变进展的IPMN,常见的或多病灶的胰腺癌,胰腺有多发转移是全胰腺切除的指征.大约35%的胰腺癌侵及邻近器官.我们的结论 是,胰腺癌患者实施多脏器联合切除术的长期生存率与标准切除术相似.扩大切除包括结肠系膜,结肠,肾上腺,肝脏,胃.因此,为获得治愈性切除,对波及邻近器官的肿瘤实施扩大切除术是正确的.对胰腺癌局部复发的病患,最近的研究支持＂只要有可能,即实施外科探查和切除＂的概念.这种方法 可与术中放疗联合进行.为得到最佳结局,多学科的序贯治疗非常有必要.

Multiple von Meyenburg complexes mimicking diffuse liver metastases from esophageal squamous cell carcinoma

Von Meyenburg 建筑群是由腺瘤组成的良性的肝损害胆汁管增殖。我们在场患食道的癌症的二个病人由 von Meyenburg 建筑群的出现伴随了。肝的外科手术前的计算机化的断层摄影术(CT ) 没显示出这些损害。在病人之一，弥漫的榴状的表明在两片肝脑叶被发现，模仿国王 diffuse 肝的转移。Intraoperative 冰冻切片在两个盒子中揭示了损害的良性的性质。没有复杂并发症，病人经历了食道的切除术。就我们的知识而言， von Meyenburg 建筑群和食道的癌症的巧合以前从来没被报导过。这个不平常的实体应该在恶意作为肝损害的鉴别诊断被考虑。它为未知起源的肝损害加重 intraoperative 冰冻切片的重要性。

Pancreatic panniculitis and elevated serum lipase in metastasized acinar cell carcinoma of the pancreas: A case report and review of literature

BACKGROUND Pancreatic panniculitis is an extremely rare condition associated with different underlying pancreatic disorders and characterized by subcutaneous fat necrosis induced by elevated serum lipase levels.These lesions usually affect the lower extremities and may precede abdominal symptoms of pancreatic disease.Acinar cell carcinoma(ACC)of the pancreas is a rare pancreatic neoplasm,accounting for only 1%-2%of pancreatic tumors in adults.We present the case of a 72-year-old man with ACC of the pancreatic head and synchronous liver metastases.Both the primary tumor and liver metastases were resected.Serum lipase was elevated before surgery and decreased to normal postoperatively.Rising serum lipase levels at follow-up led to the diagnosis of hepatic recurrence.This disease progression was then accompanied by pancreatic panniculitis,with subcutaneous fat necrosis and acute arthritis.To the best of our knowledge,only 4 cases have been reported in the literature and each showed a similar association of serum lipase levels with pancreatic panniculitis and progression of ACC.CONCLUSION Clinical symptoms and progression of ACC may correlate with serum lipase levels,suggesting potential usefulness as a follow-up biomarker.

Radioembolization for neuroendocrine liver metastases is safe and effective prior to major hepatic resection

Background:Radioembolization(RE)is well established in the treatment of neuroendocrine liver metastases.However surgery is rarely performed after RE,although liver resection is the gold standard in the treatment of localized neuroendocrine liver metastases.Therefore,aim of the present study was to evaluate the safety and feasibility of liver resection after RE in a homogenous cohort.Methods:From a prospective surgical(n=494)and nuclear medical(n=138)database patients with NELM who underwent liver resection and/or RE were evaluated.Between September 2011 and December 2017 eight patients could be identified who underwent liver resection after RE(mean therapeutic activity of 1,746 Mbq).Overall and progression free survival were evaluated as well as epidemiological and perioperative factors.The surgical specimens were analyzed for necrosis,fibrosis,inflammation,and steatosis.Results:The mean hepatic tumor load of patients,who had liver surgery after RE,was 31.4%with a mean Ki-67 proliferation index of 5.9%.The majority of these patients(7/8)received whole liver RE prior to liver resection,which did not increase morbidity and mortality compared to a surgical collective.Indications for RE were oncological(6/8)or carcinoid syndrome associated reasons(2/8).Mean overall survival was 25.1 months after RE and subsequent surgery.Tumor necrosis in radioembolized lesions was 29.4%without evidence of fibrosis and inflammation in hepatic tissue.Conclusions:This is the first study analyzing the multimodal therapeutic approach of liver resection following whole liver RE.This treatment algorithm is safe,does not lead to an increased morbidity and is associated with a favorable oncological outcome.Nonetheless,patient selection remains a key issue.