Edson José Lobo

Role of EUS in the preoperative localization of insulinomas compared with spiral CT

BACKGROUND Preoperative radiologic localization of insulinomas often fails because of the small size of these tumors. Endoscopic ultrasound (EUS) can localize insulinomas in up to 80% of the cases. The aim of this study was to compare EUS and computed tomography (CT) diagnostic accuracy for insulinomas. METHODS We reviewed medical records from 12 patients (10 women) with a biochemical diagnosis of hypoglycemia and hyperinsulinism from 1 university hospital and 1 community hospital. A diagnosis of insulinoma was ultimately made in all cases and before surgery the patients underwent abdominal US, spiral CT and EUS in an attempt to precisely localize the tumor. Surgery was considered the standard for tumor localization. RESULTS Ten tumors were benign (83.3%) and 2 were malignant (16.7%). The overall sensitivity of EUS in identifying insulinomas was 83.3% compared with 16.7% for CT. Tumors not detected by EUS had a mean size of 0.75 cm. EUS-guided fine-needle aspiration was possible in only 3 patients, with a positive cytologic diagnosis in 2 (66.6%). Tumors located in the head and body of the pancreas were identified by EUS in all patients, but those located in the tail were diagnosed in only 50% of the cases. CONCLUSIONS EUS is superior to spiral CT and should replace it for the detection of pancreatic insulinomas. EUS identification depends on the site and size of the tumor.

New Trends in Diffusion-Weighted Magnetic Resonance Imaging as a Tool in Differentiation of Serous Cystadenoma and Mucinous Cystic Tumor: A Prospective Study

Background/Aims: Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions. Methods: Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients. Results: The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm2 for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI. Conclusions: DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions.

SOLID PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS

ABSTRACT Background: The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions. Aim: To analyze it´s clinical data, diagnosis and treatment. Methods: A retrospective study of medical records of all patients treated from January 1997 until July 2015. Results: Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment. Conclusions: The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.

Insulinoma de páncreas

Resumen El insulinoma es la neoplasia mas frecuente del grupo de tumores neuroendocrinos de pancreas. En el presente estudio se evaluaron los resultados clinicos e inmunohistoquimicos de 20 casos de pacientes tratados quirurgicamente desde enero de 1986 hasta diciembre de 2004. Se describio el cuadro clinico, los examenes de laboratorio e imageneologicos, y se hizo enfasis en los aspectos quirurgicos, las complicaciones y el seguimiento a medio y largo plazo. La cirugia se indico sobre la base de las evidencias clinicas y analiticas de hipoglucemia e hiperinsulinemia. En 15 pacientes se logro la localizacion previa de la lesion, en 5, su localizacion fue identificada durante la cirugia mediante la palpacion y a traves del ultrasonido intraoperatorio. Los procedimientos quirurgicos realizados con mas frecuencia fueron la reseccion pancreatica en la mitad de los pacientes y la enucleacion por laparotomia en la otra mitad. En 2 pacientes se utilizo la via laparoscopica. Dos presentaron tardiamente diabetes mellitus. La complicacion quirurgica mas frecuente fue la fistula pancreatica en 13 de los casos. No hubo mortalidad en la presente serie. En la totalidad de los pacientes se obtuvo la reversion clinica de los sintomas, caracterizada por la desaparicion de la triada de Whipple, ademas de la normalizacion o el aumento de los valores de glucemia, comparados con los valores del preoperatorio.

Insulinomas do pâncreas: diagnóstico e tratamento

BACKGROUND Despite its rarity, the insulinoma is the most common pancreatic neuroendocrine tumor. OBJECTIVE Analyze clinical and immunohistochemical data from surgical resection of the pancreas insulinoma. METHOD Twelve cases are described, concerning surgical aspects, complications and medium-long term outcome of patients. They underwent surgical treatment due to clinical suspicion and biochemical diagnosis of hypoglycemia and hyperinsulinism. RESULTS The insulinoma was identified preoperatively in seven patients, while intraoperative ultrasonography and palpation were necessary for diagnosis in the other cases. Eight patients underwent pancreatic resection and pancreatic leak was observed in seven cases. Two patients developed diabetes mellitus and no mortality occurred in the current series. CONCLUSION All patients presented satisfactory outcome and remained asymptomatic with normal glicemia levels.

Proposição de videolaparoscopia em ratos

Os autores apresentam a possibilidade do uso da videolaparoscopia em ratos. Foram utilizados 10 ratos Wistar. Empregaram um optica de 3mm, 30 graus, usada em artroscopia. Obtiveram bo visibilizacao dos orgaos da cavidade peritoneal. A introducao de agulhas especiais e instrumentos delicados permitiram realizar os procedimentos operatorios. O modelo experimental proposto tornou-se viavel, em ratos.

Manejo atual das metástases hepáticas de câncer colorretal: recomendações do Clube do Fígado de São Paulo

Approximately half of patients with colorectal cancer present with liver metastases during the course of their disease, which directly affect prognosis and is responsible for two thirds of deaths related to the disease. In the last two decades the treatment of liver metastases from colorectal cancer (CRCLM) provided significant gain in survival when all treatment options are available to the patient. In this context, surgical treatment remains as the only chance of cure, with five-year survival rates of 25-58%. However, only 1/4 of the patients have resectable disease at diagnosis. For this reason, one of the key points in the current management of patients with CRCLM is the development of strategies that facilitate complete resection of liver lesions. The advent and refinement of ablative methods have expanded the possibilities of surgical therapy. The emergence of new chemotherapy regimens and the introduction of targeted therapies has provided high response rates and has permanently altered the management of these patients. The multimodal therapy and the involvement of different medical specialties has increasingly enabled CRCLM treatment to approached the ideal treatment, i.e., an individualized one. Based on an extensive review of literature and on experience from some of the most important specialized centers of Brazil, the Sao Paulo Liver Club began a process of multi-institutional discussions that resulted in the recommendations that follow. These recommendations, however, are not intended to be absolute, but useful tools in the therapeutic decision process for this complex group of patients.

Laparoscopic cholecystectomy in a patient with a duplicated cystic duct.

Cystic duct duplication with a single gallbladder is one of the most uncommon abnormalities of the biliary tract, with fewer than 15 instances published. The authors describe a 49-year-old patient undergoing a laparoscopic cholecystectomy in whom a second cystic duct was found, initially misdiagnosed as the biliary tract. The cholecystectomy was performed successfully with the aid of intraoperative cholangiography. It is the first time a duplicated cystic duct has been treated successfully using a laparoscopic approach.

Castleman’s Disease Mimetizing Pancreatic Tumor

CONTEXT Angiofollicular lymph node hyperplasia or Castlemans disease is a rare clinical condition. Knowledge about etiology and physiopathology; and treatment management as well are yet to be defined. Unicentric presentation of this disease affecting single lymph nodes in the mediastinum seems to be the most common presentation. Castlemans disease localized in the pancreas topographic area that mimics a pancreatic neoplasm is an even more uncommon event, with available published data of less than 15 cases until now. CASE REPORT We present a 64-year-old male patient with a six-month past history of asthenia, adynamia, and lack of general clinical conditions. Imaging studies showed a nodular hypoechoic mass in the pancreatic head. Enucleation of the lesion was performed. Histopathological study revealed unicentric form of Castlemans Disease. CONCLUSIONS Castlemans disease mimetizing pancreatic tumor is uncommon and it also curses with a difficult preoperative diagnosis. Surgery seems to be the best therapeutic alternative for this disease.

Extra-pancreatic vipoma

Neuroendocrine tumors of the pancreas are rare neoplasms representing approximately 2% of all pancreatic tumors9. Due to the progress of diagnostic imaging and radioimmunoassay, its diagnosis has become more frequent. Recent epidemiological studies suggest increased frequency12. Among the functioning tumors, vipoma (tumor cells producing vasoactive intestinal polypeptide) is also known as WDHA syndrome (watery diarrhea, hypokalaemia, and achlorhydria), Werner Morrison ́s syndrome and pancreatic cholera; it is still rare neoplasia, mainly characterized by profuse diarrhea with hydroelectrolytic disorders. It has an estimated incidence of 0,2 to 0,5 per million inhabitants per year3. Approximately 90% of these tumors originate in the pancreas; however, there are descriptions located in other segments of the gastrointestinal tract, bronchus, adrenal, sympathetic ganglia and liver. There are few cases described in the medical literature of extrapancreatic location in adults8. Due to its low incidence, it is unknown the true epidemiological data of this unique neoplasm. The objective of this report is to present another case of extra-pancreatic vipoma.