Han-Ming Chen

Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis.

BackgroundA bleeding pseudoaneurysm in patients with chronic pancreatitis is a rare and potentially lethal complication. Optimal treatment of bleeding peripancreatic pseudoaneurysm remains controversial. This study reports on experience at Chang Gung Memorial Hospital (CGMH) in managing of bleeding pseudoaneurysms associated with chronic pancreatitis.MethodsThe medical records of 9 patients (8 males and 1 female; age range, 28 – 71 years; median, 36 years) with bleeding pseudoaneurysms associated with chronic pancreatitis treated at CGMH between Aug. 1992 and Sep. 2004 were retrospectively reviewed. Alcohol abuse (n = 7;78%) was the predominant predisposing factor. Diagnoses of bleeding pseudoaneurysms were based on angiographic (7/7), computed tomographic (4/7), ultrasound (2/5), and surgical (2/2) findings. Whether surgery or angiographic embolization was performed was primarily based on patient clinical condition. Median follow-up was 38 months (range, 4 – 87 months).ResultsAbdominal computed tomography revealed bleeding pseudoaneurysms in 4 of 7 patients (57%). Angiography determined correct diagnosis in 7 patients (7/7, 100%). The splenic artery was involved in 5 cases, the pancreaticoduodenal artery in 2, the gastroduodenal artery in 1, and the middle colic artery in 1. Initial treatment was emergency (n = 4) or elective (n = 3) surgery in 7 patients and arterial embolization in 2. Rebleeding was detected after initial treatment in 3 patients. Overall, 5 arterial embolizations and 9 surgical interventions were performed; the respective rates of success of these treatments were 20% (1/5) and 89% (8/9). Five patients developed pseudocysts before treatment (n = 3) or following intervention (n = 2). Pseudocyst formation was identified in 2 of the 3 rebleeding patients. Five patients underwent surgical treatment for associated pseudocysts and bleeding did not recur. One patient died from angiography-related complications. Overall mortality rate was 11% (1/9). Surgery-related mortality was 0%.ConclusionAngiography is valuable in localizing bleeding pseudoaneurysms. In this limited series, patients with bleeding pseudoaneurysms associated with chronic pancreatitis treated surgically seemingly obtained good outcomes.

Clinicopathologic features and outcomes following surgery for pancreatic adenosquamous carcinoma

BackgroundPancreatic adenosquamous carcinoma (ASC) is a rare pancreatic malignancy subtype. We investigated the clinicopathological features and outcome of pancreatic ASC patients after surgery.MethodsThe medical records of 12 patients with pancreatic ASC undergoing surgical treatment (1993 to 2006) were retrospectively reviewed. Survival data of patients with stage IIB pancreatic adenocarcinoma and ASC undergoing surgical resection were compared.ResultsSymptoms included abdominal pain (91.7%), body weight loss (83.3%), anorexia (41.7%) and jaundice (25.0%). Tumors were located at pancreatic head in 5 (41.7%) patients, tail in 5 (41.7%), and body in 4 (33.3%). Median tumor size was 6.3 cm. Surgical resection was performed on 7 patients, bypass surgery on 3, and exploratory laparotomy with biopsy on 2. No surgical mortality was identified. Seven (58.3%) and 11 (91.7%) patients died within 6 and 12 months of operation, respectively. Median survival of 12 patients was 4.41 months. Seven patients receiving surgical resection had median survival of 6.51 months. Patients with stage IIB pancreatic ASC had shorter median survival compared to those with adenocarcinoma.ConclusionAggressive surgical management does not appear effective in treating pancreatic ASC patients. Strategies involving non-surgical treatment such as chemotherapy, radiotherapy or target agents should be tested.

Akt pathway is required for oestrogen-mediated attenuation of lung injury in a rodent model of cerulein-induced acute pancreatitis

BACKGROUNDnThe phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) is known to be an endogenous negative feedback or compensatory mechanism that serves to limit pro-inflammatory and chemotactic events in response to injury. The aim of this study is to elucidate whether Akt plays any role in 17β-estradiol (E2)-mediated attenuation of lung injury after acute pancreatitis (AP).nnnMATERIALS AND METHODSnMale Sprague-Dawley rats underwent cerulein-induced AP. Rats were treated with vehicle (cyclodextrin), E2 (1 mg/kg body weight [BW]), or E2 plus PI3K/Akt inhibitor Wortmannin (100 μg/kg BW) 1h after the onset of AP. At 8 h after sham operation or AP, various parameters were measured.nnnRESULTSnAP led to a significant decrease in lung Akt phosphorylation, which was associated with increased lung tissue myeloperoxidase (MPO) activity, wet-to-dry weight ratios, interleukin (IL)-6, tumor necrosis factor (TNF)-α, cytokine-induced neutrophil chemoattractant (CINC)-1, and CINC-3 levels. Administration of E2 after AP restored the AP-induced decrease in Akt phosphorylation and attenuated the increase in lung injury markers (MPO activity and wet-to dry weight ratios) and pro-inflammatory mediator production. The effects of E2 on the lung were abolished by co-administration of Wortmannin.nnnCONCLUSIONSnThese results collectively suggest evidences that the Akt pathway seems to be required for E2-mediated protection of lung injury after AP.

Follicular dendritic cell sarcoma mimicking giant cell carcinoma of the pancreas

Extranodal follicular dendritic cell (FDC) tumors are rare. Recognition of the morphological spectrum of FDC tumors is important to clinical diagnosis. Herein is presented a case of pancreatic FDC sarcoma with unusual clinicopathological features. A 64‐year‐old male patient presented with weight loss, poor appetite, abdominal fullness, mild anemia and mild peripheral eosinophilia. Histologically, the tumor was composed of both epithelioid and spindle cells with abundant intracytoplasmic hyaline globules. These tumor cells were positive for CD21, CD23, CD35, S‐100 protein, fascin and clusterin. Both epithelioid and spindle tumor cells independently colonized the liver and formed two tumor nodules 18u2003months after the initial resection. Notably, the two hepatic metastases additionally acquired patchy expression of human leukocyte antigen‐DR. The epithelioid FDC in one of the hepatic lesions transformed into numerous bizarre giant cells, which could easily be confused with a metastatic giant cell carcinoma from the pancreas. FDC tumor should therefore be included in the differential diagnoses when dealing with a giant cell tumor.

Pancreaticoduodenectomy Versus Frey's Procedure for Chronic Pancreatitis: Preliminary Data on Outcome and Pancreatic Function

PurposeSeveral surgical treatments have been proposed for treating chronic pancreatitis (CP), including standard pancreaticoduodenectomy (PD), pylorus-preserving PD, Begers procedure, and Freys procedure; however, few studies have compared pre- and postoperative pancreatic function in patients undergoing surgery for CP.MethodsBetween 1996 and 2003, 42 patients with CP underwent pancreatic head resection; as PD in 17 and as Freys procedure in 25. Freys procedure was chosen if the pancreatic duct was dilated more than 5u2009mm. We conducted this prospective, nonrandomized study to compare the pre- and postoperative status after PD or Freys procedure by evaluating pancreatic function and symptom relief.ResultsThe demographic features, surgical morbidity, and mortality were similar in the two groups. Pancreatic exocrine function improved, pain subsided, and complications of the adjacent organs resolved after surgery in both groups. Similar postoperative endocrine and exocrine functional results were observed in both groups. Freys procedure was associated with a significantly shorter hospital stay than PD (10.6 versus 15.4 days, respectively; (P < 0.0001)).ConclusionThere were no significant difference in operative time, surgical morbidity, or mortality rates between PD and Freys procedure. Both procedures were equally effective in terms of pain relief, improvement of pancreatic exocrine function, and control of complications affecting the adjacent organs; however, Freys procedure was associated with a significantly shorter hospital stay.

Primary angiosarcoma of the spleen in a child with long-term survival

Primary angiosarcoma of the spleen is a very rare and aggressive neoplasm with poor prognosis. Splenic angiosarcoma rarely occurs in the pediatric group (18xa0years or younger). Survival duration for pediatric patients is very limited. We report a 7-year-old boy with splenic angiosarcoma presented with left upper quadrant abdominal pain and a palpable abdominal mass. Hematogram revealed anemia. Abdominal ultrasound revealed a heterogeneous mass about 12xa0cm in diameter in the left upper abdomen. Abdominal computed tomography demonstrated a huge heterogeneous mass with some cystic components closely attached to the spleen. Splenectomy was performed. Histological examination of the surgical specimen showed that this tumor had typical feature of angiosarcoma including vasoformative architecture, highly pleomorphic tumor cells with irregular, hyperchromatic and prominent nucleoli, and some mitosis. The postoperative course was uneventful. The patient was disease free at 16xa0years after surgery. This is the longest reported duration of survival in a patient with splenic angiosarcoma.

Clinicopathologic Features and Predictors for Survival of Mucinous and Nonmucinous Appendiceal Adenocarcinoma

Background/Aims: We report a study in patients with mucinous and nonmucinous appendiceal adenocarcinoma treated surgically whose records were examined to elucidate their clinicopathologic features and prognostic factors for survival. Methods: The medical records of 34 patients with mucinous and nonmucinous appendiceal adenocarcinoma (1991–2005) were retrospectively reviewed. Results: There was no significant difference between mucinous and nonmucinous tumors in patient demographics, clinicopathologic features, type of operation and outcome. Nonmucinous tumors had a higher incidence of leukocytosis than mucinous ones. The overall 5-year survival rate for 34 patients with appendiceal adenocarcinoma was 35.8%. In the univariate analysis, predictors of survival were the type of operation, resectability, carcinomatosis and tumor stage. Tumor stage significantly influenced patient survival in the multivariate analysis. Conclusion: Mucinous appendiceal adenocarcinoma had clinicopathologic characteristics and a prognosis similar to nonmucinous, except that there was more leukocytosis in nonmucinous tumors. Tumor stage is an independent predictor for survival among patients with appendiceal adenocarcinoma.

Management of Bleeding Pseudoaneurysm with Arterial Embolization in ERCP-related Pancreatitis: Report of a Case

Peripancreatic pseudoaneurysms result either from enzymatic insult to pancreatic and peripancreatic arteries or from erosion of a pseudocyst into adjacent visceral arteries. A Peripancreatic pseudoaneurysms result either from enzymatic insult to pancreatic and peripancreatic arteries or from erosion of a pseudocyst into adjacent visceral arteries. A bleeding pseudoaneurysm is a rare complication of acute pancreatitis, and management of bleeding pseudoaneurysms is still a challenge for clinicians because it is associated with a high mortality rate. We here report on a 54-year-old male patient suffering from acute pancreatitis related to endoscopic retrograde cholangiopancreatography. He received aggressive medical treatment, since persistent fever and abdominal pain were identified for 3 weeks. Laparotomy was performed under the impression of pancreatic necrosis and abscess. During the operation, much fresh and clotted blood was found to have accumulated in the right subphrenic space and Morisons pouch. Active oozing and a circumferential seromuscular tear in the second-portion of the duodenum were identified. The bleeding pseudoaneurysm was identified postoperatively by means of angiography and was successfully treated with arterial embolization. Pyloric exclusion and subsequent gastrojejunostomy were performed to treat the duodenal injury. The patient was discharged home on the 33rd day after the first surgery with no evidence of rebleeding or sequelae over the following 24 months.

Preservation of Ampulla of Vater for Severe Corrosive Upper Gastrointestinal Injury

We report a case of extensive surgery including esophago-gastro-duodenojejunectomy, preserving the ampulla of Vater and the orifice of the accessory pancreatic duct, for severe corrosive upper gastroi