Intraoperative pancreatoscopy with narrow band imaging: a novel method for assessment of resection margins in case of intraductal papillary mucinous neoplasm.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is characterized by intraductal proliferation of neoplastic mucinous cells with a variable extent along the main duct or its branches. The lesion may be continuous or discontinuous. Skip lesions have been described in about 6-19% of cases. Complete resection without leaving behind any skip lesions is important, to such an extent that many groups suggest even total pancreatectomy, a major and morbid surgery. METHODS: A 40 year-male patient with chronic pancreatitis presented with recent-onset diabetes mellitus and weight loss. Ultrasound and computed tomography (CT) scan showed a cystic lesion in the head and uncinate process of pancreas. Peroral pancreatoscopy showed villous projections with dilated tortuous vessel in the head, suspicious of IPMN. The duct beyond pancreatic head could not be visualized and remained unassessed. At pancreatoduodenectomy, pancreatoscopy with narrow band imaging (NBI) was done using flexible pancreatoscope through the cut end of the duct at the neck to assess the duct in the body and tail. RESULTS: Pancreatoscopy with NBI showed a normal-looking resection margin and a skip lesion 1 cm beyond it. The revised resection margin confirmed the skip lesion on frozen section and also that the fresh cut margin was negative. The remaining duct in the body and tail was normal on pancreatoscopy. Total clearance of the disease could be achieved without a major procedure such as total pancreatectomy. CONCLUSIONS: Intraoperative pancreatoscopy, especially with NBI, is a good diagnostic tool for IPMN and also helps in intraoperative decision-making of the resection margins.

Vascular anatomy of strictured small bowel.

AIM: To investigate the role of ischemia in the pathogenesis of small bowel strictures. METHODS: Vascular anatomy of 39 small bowel strictures was studied using modified Spalteholtz method. Ten normal small bowel segments were studied as controls. RESULTS: 71.8% of small bowel strictures showed block in the mesenteric vessels (p=0.008). Subset analysis of tuberculous strictures showed block in the mesenteric vessels in 70.8% of strictures (p=0.0098). CONCLUSIONS: Ischemia plays a significant role in the pathogenesis of small bowel strictures. Mesenteric vasculopathy has a significant association with tuberculous strictures of the intestine.

Hepatic cholesterol transporter ABCG8 polymorphisms in gallstone disease in an Indian population.

BACKGROUND AND AIM: Gallstone formation is characterized by the abnormal regulation of cholesterol trafficking and solubilization. The prevalence of gallstone disease (GSD) differs between ethnic groups sharing the common environment. These differences can be explained by a genetic predisposition to gallstone formation. Studies have identified single nucleotide polymorphisms (SNP) D19H and T400K in the cholesterol transporter gene ATP-binding cassette, subfamily G, member 8 (ABCG8) in patients with cholesterol gallstones. The aim of this study was to analyze the relationship between D19H and T400K polymorphisms in the ABCG8 gene and GSD in an Indian population, and the effects of these polymorphisms on cholesterol levels in sera and bile. METHODS: A total of 226 patients with GSD were analyzed for their lipid profile in plasma and bile. A total of 289 controls were recruited, and their plasma lipid profile was analyzed by standard protocols. The genotype of SNP D19H and T400K of ABCG8 was analyzed in 226 patients and 222 control samples. SNP D19H was analyzed by direct sequencing, and SNP T400K genotyping was assayed by the amplification refractory mutation system-polymerase chain reaction. RESULTS: There was no significant difference in the allelic distribution of SNP T400K between the GSD and gallstone-free groups (P > 0.05), but the distribution of the SNP variant, D19H, was significantly higher (P = 0.017, odds ratio = 2.274) in patients compared to controls. The analysis of serum and bile cholesterol followed a strong association with genotypes. CONCLUSION: SNP D19H, but not SNP T400K, in the ABCG8 gene is significantly associated with GSD in an Indian population.

NOTES: a review.

A few years ago a new approach to performing abdominal surgery was presented, i.e. via the natural body orifices using endoscopes. The interest and research in this approach progressed very rapidly, in spite of the initial skepticism. It was initially demonstrated in animal models, then in human beings and has now very nearly become routine practice. This article reviews the development of natural orifice transluminal endoscopic surgery (NOTES), its benefits and the hurdles we have yet to overcome.