Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy

AIM:To determine predictors of clinically relevant pancreatic fistulas(CRPF)by measuring drain fluid amylase(DFA)in the early postoperative period.METHODS:This prospective clinical study included382 patients with periampullary tumors that were surgically resected at our department between March 2005and October 2012.A cephalic duodenopancreatectomy (DP)was performed on all patients.Two closed suction drains were placed at the end of the surgery.The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer.Pancreatic fistula(PF)was classified according to the International Study Group of Pancreatic Fistula(ISGPF)criteria.Postoperative complications were defined according to the Dindo-Clavien classification.All data were statistically analyzed.The optimal thresholds of DFA levels on the first,second and third postoperative days were estimated by constructing receiver operating curves,generated by calculating the sensitivities and specificities of the DFA levels.The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula(BPF)and CRPF.RESULTS:Pylorus-preserving duodenopancreatectomy was performed on 289(75.6%)patients,while the remaining patients underwent a classic Whipple procedure(CW).The total incidence of PF was 37.7%(grade A22.8%,grade B 11.0%and grade C 3.9%).Soft pancreatic texture(SPT)was present in 58.3%of patients who developed PF.Mortality was 4.2%.The median DFA value on the first postoperative day(DFA1)in patients who developed PF was 4520 U/L(range 350-99000 U/L)for grade A fistula(BPF)with a SPT and a diameter of the main pancreatic duct(MPD)of≤3 mm.For grade B/C(CRPF),the median DFA1 value was 8501 U/L(range377-92060 U/L)with a SPT and MPD of≤3 mm.These values were significantly higher when compared to the patients who did not have PF(122;range 5-37875 U/L).The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were:DFA1 1200U/L for the BPF and CRPF;DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF.The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF.CONCLUSION:DFA1≥1200 U/L is an important predictive factor for PF of any degree.The trend of DFA3(decrease of<50%)compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.

Extensive multiarterial resection attending total duodenopancreatectomy and adrenalectomy for MEN-1-associated neuroendocrine carcinomas

Pancreatic neuroendocrine tumors(PNTs) are relatively uncommon although these neoplasms have been noted to grow in occurrence in recent decades.Surgical removal of locally advanced PNTs involving major vessels and adjacent organs is warranted by reason of an appreciably more favorable prognosis as compared to exocrine pancreas cancer.We are reporting a case of successful multi-organ resection combined with a wide excision of the superior mesenteric,common,proper,left and right hepatic arteries(in the presence of the hepatomesenteric trunk variant of aberrant arterial anatomy) for multifocal PNTs in the setting of multiple neuroendocrine neoplasia type 1 syndrome.The procedure resulted in pain abolition,a significant improvement in the patient's life quality and allowed her to return to work.Follow-up computed tomography at 15 mo post-surgery showed no evidence of disease recurrence.

Biliary tree gastrinomas in multiple endocrine neoplasia type 1 syndrome

AIM:To describe our patients affected with ectopic biliary tree gastrinoma and review the literature on this topic.METHODS:Between January 1992 and June 2012,28 patients affected by duodenopancreatic endocrine tumors in multiple endocrine neoplasia type 1(MEN1)syndrome underwent surgery at our institution.This retrospective review article analyzes our experience regarding seventeen of these patients subjected to duodenopancreatic surgery for Zollinger-Ellison syndrome(ZES).Surgical treatment consisted of duodenopancreatectomy(DP)or total pancreatectomy(TP).Regional lymphadenectomy was always performed.Any hepatic tumoral lesions found were removed during surgery.In MEN1 patients,removal of duodenal lesions can sometimes lead to persistence or recurrence of hypergastrinemia.One possible explanation for this unfavorable outcome could be unrecognized ectopic localization of gastrin-secreting tumors.This study described three cases among the seventeen patients who were found to have an ectopic gastrinoma located in the biliary tree.RESULTS:Seventeen MEN1 patients affected with ZES were analyzed.The mean age was 40 years.Fifteen patients underwent DP and two TP.On histopathological examination,duodeno pancreatic endocrine tumors were found in all 17 patients.Eighty-one gastrinomas were detected in the first three portions of the duodenum.Only one gastrinoma was found in the pancreas.The mean number of gastrinomas per patient was 5(range 1-16).Malignancy was established in 12 patients(70.5%)after lymph node,liver and omental metastases were found.Three patients exhibited biliary tree gastrinomas as well as duodenal gastrinoma(s).In two cases,the ectopic gastrinoma was removed at the same time as pancreatic surgery,while in the third case,the biliary tree gastrinoma was resected one year after DP because of recurrence of ZES.CONCLUSION:These findings suggest the importance of checking for the presence of ectopic gastrinomas in the biliary tree in MEN1 patients undergoing ZES surgery.

Annular pancreas associated with duodenal carcinoma

Annular pancreas (AP) is a rare congenital anomaly. Coexisting malignancy has been reported only in a few cases. We report what is, to the best of our knowledge, the first case in the English literature of duodenal adenocarcinoma in a patient with AP. In a 55-year old woman with duodenal outlet stenosis magnetic resonance cholangiopancreatography showed an aberrant pancreatic duct encircling the duodenum. Duodenojejunostomy was performed. Eight weeks later she presented with painless jaundice. Duodenopancreatectomy revealed a duodenal adenocarcinoma, surrounded by an incomplete AP. Thus, co-existent malignancy with AP can be present without obstructive jaundice and without being visible through preoperative diagnostics.