Daniel Van Gansbeke

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series

BACKGROUND Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. METHODS Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. RESULTS Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). CONCLUSIONS This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results

BACKGROUND In severe chronic pancreatitis associated with intraductal stones, therapeutic endoscopy aims to reduce increased intraductal pressure by pancreatic sphincterotomy and stone clearance. METHODS Results of treatment were evaluated in 70 new patients who underwent pancreatic sphincterotomy and attempted stone removal. Technical results and frequency of pain relief and recurrence are compared. RESULTS Complete ductal clearance of calculi was obtained in 50% of cases. Immediate clinical improvement occurred in 95% of patients with painful attacks. No severe complications or mortality occurred. Fifty-four percent of all patients with painful chronic pancreatitis did not experience any pain recurrence within 2 years. Associations found to be statistically significant by multivariate analysis were ductal clearance and extracorporeal shock wave lithotripsy, pain disappearance and ductal clearance, pain recurrence and long evolution, and severe disease before treatment and presence of a ductal substenosis. CONCLUSIONS In this subset of patients our results indicate that the pain of chronic pancreatitis is mainly related to increased intraductal pressure. Endoscopic management appears to be a safe, conservative, alternative to surgery. The best results are obtained when it is performed early in the course of calcifying chronic pancreatitis.

Transcatheter Embolization of Pseudoaneurysms Complicating Pancreatitis

AbstractPurpose: To evaluate the therapeutic role of angiography in patients with pseudoaneurysms complicating pancreatitis. Methods: Thirteen symptomatic pseudoaneurysms were treated in nine patients with pancreatitis. Eight patients had chronic pancreatitis and pseudocyst and one had acute pancreatitis. Clinical presentation included gastrointestinal bleeding in seven patients and epigastric pain without bleeding in two. All patients underwent transcatheter embolization. Results: Transcatheter embolization resulted in symptomatic resolution in all patients. Rebleeding occurred in two patients, 18 and 28 days after embolization respectively, and was successfully treated by repeated emnbolization. One patient with severe pancreatitis died from sepsis 28 days after embolization. Follow-up was then available for eight patients with no relapse of bleeding after a mean follow-up of 32 months (range 9—48 months). Conclusion: Transcatheter embolization is safe and effective in the management of pseudoaneurysms complicating pancreatitis.

Mesenteric vein thrombosis: Early CT and US diagnosis and conservative management

We report a case of isolated superior mesenteric vein thrombosis with acute ischemic bowel disease, diagnosed early by a screening ultrasound scan of the upper abdomen and definitively assessed by computed tomography and angiography.This report stresses the contribution of crosssectional techniques in the early diagnosis and management of venous occlusive disease of the small bowel.

Lithiasic complications of renal transplantation: The donor graft lithiasis concept

Lithiasis is usually a late complication of renal transplantation reported in approximately 1% of all renal allografts. Underlying predisposing conditions for the formation of calculi are present in almost all cases. Preexisting stones in the donor kidney have been reported once previously. The authors have observed 2 such cases, detected by routine sonography. In 1 case, stone migration into the ureter led to acute postoperative transplant failure; this complication has never been reported previously.

Computerized morphonuclear characteristics and DNA content of adenocarcinoma of the pancreas, chronic pancreatitis, and normal tissues: Relationship with histopathologic grading

We report the morphonuclear characteristics of normal (13 cases), benign (ie, chronic) pancreatitis (six cases), and neoplastic (ie, ductal) adenocarcinoma (22 cases) tissues of the pancreas. This description is based on computerized cell image analysis, which permits the determination of parameters related to the morphometric (nuclear area), densitometric (nuclear DNA content), and chromatin texture features of Feulgen-stained nuclei from paraffin-embedded archival material. We observed that nuclear area discriminates between normal and benign (ie, chronic pancreatitis) as opposed to neoplastic cell nuclei. Morphonuclear parameters describing chromatin pattern characteristics made it possible to discriminate between grade I pancreatic carcinoma and normal and benign cell nuclei on the one hand, and grades I and III carcinoma on the other hand. The nuclear DNA content increased in a continuous manner from normal and benign through low-grade to high-grade neoplastic tissues of the pancreas. Combining the morphometric, densitometric, and textural parameters into one equation, we were able to calculate a score (ie, the malignancy level index) that showed a close relationship to conventional histopathologic grading. Thus, the computer-aided diagnosis of cytologic specimens from pancreatic lesions offers information of the same significance as that obtained by conventional histopathologic grading.

Hepatic Artery Aneurysm: CT and MR Features

The authors report a case of common hepatic artery aneurysm diagnosed by computed tomography (CT) and magnetic resonance (MR). Features of both techniques are described and discussed. The surgical and radiologic literature is reviewed.

Sonographic demonstration of portal venous system thromboses secondary to inflammatory diseases of the pancreas

Sonographic demonstration of abdominal venous thromboses subsequent to pancreatic benign inflammatory diseases has been seldom reported up to now. Seven cases of thromboses of the portal venous system associated with acute or chronic pancreatitis are reported. All cases were detected by sonography in patients without clinical manifestations of portal hypertension. Echogenic thrombus within the lumen of the vein was observed only in the short-term follow-up of acute pancreatitis. Cavernomatous transformation was observed in 6 patients with long-term calcifying pancreatitis. Extrinsic compression by pseudocyst of the pancreas was observed in only 1 case. In all the other cases, thromboses seems to be secondary to local inflammatory phenomena during previous episodes of acute pancreatitis.

Percutaneous drainage of subphrenic abscesses

Forty subphrenic abscesses were drained percutaneously in 37 patients. These abscesses were subsequent to abdominal surgery (28 patients), biliary obstruction and/or fistula (six patients), trauma (two patients) or acute pancreatitis (one patient). The procedures were usually monitored by duplex sonography and fluoroscopy (35 out of 40 cases), with an angled subcostal approach to the subphrenic space in over 85% of the cases. Forty-three drainage catheters were inserted using the Seldinger method; 37 (86%) had a size of 12 F or more, 21 were 16 F in size. Only two out of 43 catheters were double-lumen sump drains. The clinical condition improved after insertion of the catheter in all 37 patients. Definitive successful drainage, defined as hospital discharge without complementary surgery, was achieved in 32 patients (87%), without major complications. A temporizing effect was obtained in three additional patients (8%) who underwent curative surgery for the underlying process after complete drainage of the abscess. Two patients died from multiple organ failure before their abscess healed. Considerations for successful drainage of subphrenic abscesses include a good knowledge of the subphrenic space anatomy, the use of large-bore drainage catheters and the recognition and correct management of underlying enteric, biliary or pancreatic fistulas.

Rupture of pseudoaneurysm: a cause of delayed hemorrhage after endoscopic cystoenterostomy; angiographic diagnosis and treatment

extensive necrosis of the mucosa and multiple vascular microthrombosis found in duodenal biopsy specimens confirmed our suspicion of ischemia. Our patient had a good clinical response to conservative treatment, probably because of the limited extension of the bowel ischemia. Indeed, a second endoscopy, performed 2 weeks after admission, revealed a significant improvement. This course seems to be similar to that described for ischemic colitis, in which rapid resolution of lesions occurs in most cases.9 This report emphasizes that the clinician should look for an ischemic episode when a PNH patient presents acute abdominal pain. Unfortunately for these patients, bowel thrombosis tends to be recurrent and the overall prognosis remains poor.