New anatomical data on the drainage patterns of the uncinate process of the pancreas.

PURPOSE: Recently, progress has been made in the surgical management of benign pancreatic tumors sparing as much of the pancreatic parenchyma and pancreatic function as possible. However, the main complication of partial pancreatectomy is the disruption of pancreatic ducts ensuing leak of pancreatic secretion leading to the formation of pancreatic fistulae. In this study, we attempt to precisely define the anatomy of the branch duct draining the uncinate process which is of interest to the surgeons. METHODS: Seventeen formalin-fixed pancreases were taken and ducts were injected with a colored gelatin solution. Within the uncinate process of the pancreases, the branch duct was localized, measured and its anatomical drainage defined. Statistics were performed using Spearman's correlation test. RESULTS: The uncinate process was drained exclusively by the main pancreatic duct in ten cases, by the accessory pancreatic duct in three cases, and by both the ducts in four cases. All of the branches drained into the main pancreatic duct downstream to the junction between the main and the accessory pancreatic duct, except for one. CONCLUSIONS: We have precised the possibility of double drainage of the uncinate process, but this could not be correlated with simple anatomical or radiological landmarks such as the length of the main pancreatic duct or the patency of the minor duodenal papilla.

Long-term survival (5-20 years) after pancreatectomy for pancreatic ductal adenocarcinoma: a series of 30 patients collected from 3 institutions.

OBJECTIVES: Long-term survival after pancreatectomy for pancreatic duct adenocarcinoma has been rarely reported. Factors influencing survival are still debated. The aim of the study is to report a French multicentric series of long-term survivors after pancreatectomy for pancreatic duct adenocarcinoma. METHODS: Data of patients who survived >5 years (February 1983-January 2000) were analyzed. All operative specimens were reviewed. Patients with intraductal-papillary-mucinous-neoplasia, cystadenocarcinoma, acinous-adenocarcinoma, neuroendocrine, or mixed tumors were excluded. RESULTS: Long-term survivors were 20 men and 10 women, with median age of 61 years. Twenty-five patients had pancreaticoduodenectomies (6 pylorus preserving pancreatoduodenectomy [PPPD]), 3 had total pancreaticoduodenectomies, and 2 had splenopancreatectomies. Three patients had portal vein resection, 1 had hepatic artery resection-reconstruction, and 1 had segmentectomy for liver metastasis. All resections were complete macroscopic and microscopic resection (R0). Median tumor size was 30 mm. Tumors were pT2 (n = 1), pT3 (n = 24), pT4 (n = 5), 12 N+, 1 M+. Twenty patients had adjuvant radiotherapy, and 18 had concomitant chemotherapy. Median survival was 7.3 years (range, 5.2-21 years). Nineteen patients are alive, 1 with recurrence and 18 with no evidence of disease (2 had more than 20 years of follow-up). Eleven patients died, 6 from recurrence. CONCLUSIONS: Pancreatic duct adenocarcinoma can be cured, and long-term survival after R0 curative surgery has become a reality. Long-term survivors did not fulfil the ideal prognostic criteria and even presented with advanced stage.

Cystic dystrophy of the duodenal wall developing in heterotopic pancreas: report of 9 cases.

OBJECTIVE: Cystic dystrophy in heterotopic pancreas (CDHP), an uncommon but serious complication of dilatation of the ectopic pancreatic ducts of heterotopic pancreatic tissue, occurs most often in the second part of the duodenum. This disorder is difficult to diagnose and raises various therapeutic questions. The aim of this study was to evaluate the most useful procedures for investigating suspected CDHP and to consider late results after surgical treatment by pancreaticoduodenectomy (PD). METHODS: This retrospective study concerned 9 patients who developed CDHP of the duodenal wall during an 18-year period (1983-2001). All patients were symptomatic and underwent PD (no postoperative deaths). Clinical presentation, imaging findings, pathological features, and follow-up were analyzed. RESULTS: All patients but one were male alcoholics (mean age, 48 years; range, 37-63 years). The clinical presentation was abdominal pain (n = 9) associated with vomiting (n = 6), jaundice (n = 2), and weight loss (n = 9). Upper endoscopy (n = 9) showed nonspecific inflammatory lesions with duodenal stenosis (n = 4). Retrospective analysis of computed tomographic findings (n = 9) studied specific signs of CDHP and nonspecific inflammatory changes in periduodenal space. Endoscopic ultrasonography (n = 4) and magnetic resonance cholangiopancreatography (n = 2) were the most useful investigations. Pathological findings in surgical specimens were multiple cysts located in the thickened duodenal wall (n = 9), ectopic pancreatic tissue (n = 7), fibrosis of the normal gland (n = 4), and adenocarcinoma in ectopic tissue (n = 1). During the follow-up period, 4 patients died 12, 16, 48, and 72 months after PD. The cause of death was independent of CDHP or PD, but related to persistent alcoholism in 2 cases involving chronic pancreatitis. In 1 case, the patient died of disseminated adenocarcinoma. The other 5 patients had a good result. CONCLUSION: Endoscopic ultrasonography and magnetic resonance pancreatography are the most useful investigations for the diagnosis of CDHP. Pancreaticoduodenectomy is justified after failure of medical treatment or endoscopic drainage. Late results after PD are dependent on alcoholic consumption when CDHP is associated with chronic pancreatitis.

[The solitary rectal ulcer syndrome]. / Le syndrome de l'ulcère solitaire du rectum.

The solitary rectal ulcer syndrome is a rare debilitating disorder of the rectum characterized by perianal chronic pain with passage of blood and mucus. The pathogenesis remains uncertain, rectal prolapse and trauma from straining are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypoïd lesion) and histological features. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. The treatment is controversial including a conservative option (medications and behavioural therapy) with poor long term results, and the surgical option (treatment of a rectal prolapse with or without resection of the lesion), more aggressive with uncertain results in a long follow-up period.

[Rectal Abrikossof tumor: a rare location]. / Tumeur d'Abrikossof rectale: une localisation inhabituelle.

Granular cell tumors or Abrikossof tumors are neurogenous ubiquitary submucosal-like tumors that are usually benign. The most frequent locations are the skin and buccal cavity. The usual location in the digestive tract is the esophageal wall. We report a rare case of Abrikossof tumor of the rectum that was not operated on because of a certain diagnosis and a low risk of malignancy.

[Gangrene of the ligamentum teres hepatis]. / Gangrène isolée du ligament rond du foie.

Necrosis of the ligamentum teres hepatis is a very rare and misdiagnosed pathology. Four cases have been reported in the literature. Clinical symptoms with acute abdominal pain suggest peritonitis. The diagnostic may be obtained by CT scan of the abdomen revealing a hypo/dense circular lesion, anterior to the liver, to the junction of the segments III and IV, associated with inflammation. The mechanism of isolated necrosis of the round liver ligament remains unclear. In the absence of a preoperative diagnosis, a video-laparoscopic exploration is proposed.

Intraductal papillary-mucinous tumors of the pancreas: predictive criteria of malignancy according to pathological examination of 53 cases.

BACKGROUND: One of the main problems in the management and treatment of intraductal papillary-mucinous tumors is the lack of a reliable predictive factor for malignancy. HYPOTHESIS: Surgical treatment could be adapted to macroscopic criteria (presence of mural nodules and diameter of the pancreatic duct and of the lesion) or to tumor location (main duct, branch duct, or combined lesions) associated with benign or malignant forms. DESIGN: Retrospective study. SETTING: Two university and tertiary referral centers. PATIENTS: Fifty-three consecutive patients who underwent pancreatic resection for intraductal papillary-mucinous tumors between January 1, 1985, and December 31, 2000. RESULTS: Macroscopic analyses of tumors showed 6 main duct lesions, 12 branch duct lesions, and 35 combined lesions. A carcinoma was present in 33 cases (62%): 22 (41%) were invasive and 11 (21%) were noninvasive; 9 (17%) were borderline tumors and 11 (21%) were benign. Carcinoma and invasive carcinoma forms were less frequent in branch duct lesions (P<.001 and P =.009, respectively). Mural nodules were more frequent in carcinomas (P =.006) and invasive carcinomas (P<.001), with a positive predictive value of malignancy of 81%. The diameter of lesions (branch duct lesion > or =30 mm) or main duct (main pancreatic duct > or =15 mm in combined or main pancreatic duct lesions) did not correlate with malignancy. CONCLUSIONS: No carcinoma occurred in branch duct types smaller than 30 mm without mural nodules. Limited resection may be appropriate only in this type of tumor.

[Cystic and intraductal tumors of the pancreas]. / Tumeurs kystiques et canalaires du pancréas.

The management of cystic and intraductal pancreatic tumours has changed over the last ten years due to increasing fortuitous discovery of incidental cystic lesions of the pancreas and better knowledge of these lesions. CT-scan or MRI can usually differentiate the two most frequent cystic tumours: benign serous cystadenoma and potentially malignant mucinous cystadenoma. Conservative management is wholly justified for serous cystadenoma without complications, whereas mucinous cystadenoma can be cured by pancreatic resection. In case of doubt, endoscopic ultrasonography and study of cystic fluid may be helpful. Recently identified intraductal papillary mucinous neoplasms of the pancreas are premalignant or malignant tumours of the pancreatic ducts clearly visualized by magnetic resonance pancreatography. Curative pancreatic resection should be performed before the invasive adenocarcinoma stage.

Elevated (> or = 10%) MIB-1 proliferative index correlates with poor outcome in gastric stromal tumor patients: a study of 35 cases.

Mitotic activity and tumor size are currently regarded as the most powerful prognostic indicators for patients with gastrointestinal stromal tumor (GIST). This retrospective study evaluated the prognostic accuracy of MIB-1 proliferative index (PI) in combination with these two indicators in 35 GIST patients. Within a high-risk group, determined initially by tumor size and mitotic count, overall survival was significantly shorter for patients whose tumors had PI > or = 10% MIB-1 positive cells. When tumor location (gastric versus small intestine) was taken into account, a combination of tumor size, mitotic count, and PI > or = 10% identified a subgroup of patients with significantly shorter survival for gastric (but not small intestinal) GIST. Based on our results, MIB-1 immunostaining, when used in combination with tumor size and mitotic count, appears to be a powerful tool for identifying patients, especially those with gastric tumors, at high risk of recurrence and early tumor-related death.