[Total pancreatectomy for mucinous pancreatic tumor]

AIM OF THE STUDY

To report our experience of total pancreatectomy (TP) in ten patients with mucinous pancreatic tumors (MPT), to discuss pre and peroperative investigations in the management of MPT, and operative, functional and carcinologic results after TP.

PATIENTS AND METHODS

This retrospective study from January 1985 to January 2001 included ten patients, 5 men and 5 women (mean aged: 64 years). Six patients underwent one step TP for intraductal papillary mucinous tumor of the pancreas (IPMT) in 5 cases, and multifocal mucinous cystadenoma in one case. Four patients underwent a second step TP for tumor recurrence (2 IPMT, and 2 cystadenocarcinomas) which occurred 12 to 121 months post operatively (mean: 49 months).

RESULTS

Post TP diabetes was controlled by insulinotherapy (3 injections a day), except in one patient who needed insulin administration through a pump. One patient, with cystadenocarcinoma, died from cancer recurrence 18 months after TP and 140 months after the initial pancreaticoduodenectomy. One patient died from heart disease 34 months postoperatively. The 8 other patients were alive with a mean follow-up of 33 months (range 11-61 months).

CONCLUSION

Curative surgery for mucinous tumors of the pancreas may require TP, which is indicated preoperatively according to imaging, or intraoperatively following surgical findings and frozen section of the pancreatic margin. Totalization of a previous partial pancreatectomy is mandatory in case of tumoral persistence or recurrence in the pancreatic remnant. Postoperative diabetes can be managed successfully by a specialized team.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]

STUDY AIM

Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas.

MATERIAL AND METHODS

15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%).

RESULTS

Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection.

CONCLUSION

Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy

BACKGROUND

It remains debatable whether somatostatin can prevent pancreatic fistula and other pancreatic stump-related complications following pancreaticoduodenectomy. This study assessed the effects of somatostatin-14 (S-14) on pancreatic remnant exocrine secretion.

METHODS

This was a double-blind, randomized, placebo-controlled trial in patients undergoing pancreaticoduodenectomy for malignancy. Patients received a continuous infusion of S-14 (n = 38) or placebo (n = 37) for 7 days. Pancreatic juice and peripancreatic drainage fluid was collected and measured, and pancreatic enzymes were monitored daily. Postoperative complications were recorded.

RESULTS

S-14 infusion was associated with a decrease in median daily pancreatic juice and pancreatic amylase output. Amylase concentration and output in the peripancreatic drain fluid were significantly lower after S-14 infusion than in the control group (both P < 0.05). The incidence of clinical pancreatic fistula (two of 38 versus eight of 37; P < 0.05) and total pancreatic stump-related complications (five of 38 versus 12 of 37; P < 0.05) was lower in patients treated with S-14. Duration of hospital stay was shorter after S-14 (18 versus 26 days; P = 0.01).

CONCLUSION

Although the effect of S-14 on exocrine secretion remains difficult to demonstrate, it did reduce pancreatic juice leakage from the pancreatic remnant.

Cystic endocrine tumors of the pancreas: clinical, radiologic, and histopathologic features in 13 cases

Cystic endocrine tumors of the pancreas are rare and raise difficult clinical problems. Our aims were to reevaluate the diagnostic and therapeutic strategy and to assess their histopathologic characteristics. Thirteen cystic endocrine tumors diagnosed in 10 patients were included. Clinical, radiologic, and pathologic data were reviewed. There were 6 male and 4 female patients (median age, 46 yrs). Six patients had evidence of multiple endocrine neoplasia type 1 (MEN1) disease. Four had a functional endocrine syndrome. Ten tumors were visible on imaging studies. The most suggestive radiologic features were the existence of a peripheral hypervascular rim (10 cases) and images of cyst into cyst (two cases). On gross and histologic examinations, two distinct types were present. Macrocystic tumors (six cases) were unilocular and limited by a thick wall containing nests of tumor cells. Microcystic tumors (seven cases) were characterized by the presence of multiple cystic spaces directly lined by tumor cells. Surgical resection was performed in all cases. Three patients had lymph node metastases at the time of diagnosis. One patient is dead with metastatic dissemination. The others are alive without recurrence or metastasis. The diagnosis of endocrine tumor must be considered for any pancreatic cyst discovered in a patient with a history of MEN1 syndrome or with clinical features suggestive of this syndrome. Cystic pancreatic endocrine tumors must be treated by surgical resection because of their possible malignant evolution.

[Hepatobiliary cystic tumors. Clinical, radiological and histopathological study of 7 cases]

OBJECTIVES

Hepatobiliary cystic tumors are rare, but must be correctly diagnosed because of their potential malignancy. We report the clinical, radiological, pathological and evolutive characteristics of 7 cases of hepatobiliary cystic tumors.

MATERIAL AND METHODS

Complete clinical charts were available. Radiological and pathological documents were reviewed.

RESULTS

There were 4 females and 3 males (median age, 58.7 yrs). In 3 cases, the presenting symptom was the palpation of a mass in the right upper abdominal quadrant. In 6 cases, pre-operative imaging studies showed a cystic intra-hepatic mass, containing vegetations and/or septa in 5 cases. In the remaining case, the radiological appearance showed a heterogeneous liver mass. Two patients were treated by pericystectomy and 5 by radical hepatectomy. At macroscopic examination, tumors were usually large (range: 2-24 cm) and multilocular. Histological diagnosis was: cystadenoma with mesenchymous stroma (2 cases), mucinous cystadenoma (2 cases), mucinous cystadenocarcinoma (2 cases), giant cell cystadenocarcinoma (1 case). The mean duration of follow up was 60 months. Two patients, both with cystadenocarcinomas, died after respectively, 21 and 34 months with metastatic dissemination. Five patients are alive without evidence of disease after a delay ranging from 14 to 144 months.

CONCLUSION

Radical surgical treatment of cystic hepatobiliary tumors is necessary to obtain histopathological examination of the complete specimen, which is essential for a correct evaluation of the malignant potential of the lesion, and for prolonged survival, even in cases of locally invasive tumors.

Intra-arterial iodine 131-labeled lipiodol as adjuvant therapy after curative liver resection for hepatocellular carcinoma: a phase 2 clinical study

HYPOTHESIS

Intra-arterial lipiodol labeled with iodine 131 ((131)I-lipiodol) can be safely used as adjuvant therapy following curative liver resection for hepatocellular carcinoma (HCC).

DESIGN

Phase 2 pilot study.

SETTING

Large teaching hospital.

PATIENTS

Twenty-eight patients (24 men and 4 women; median age, 61.5 years; range, 33-75 years) were treated from January 1991 to June 1997. The liver was cirrhotic in 7 cases and noncirrhotic in 21 cases. An equal number of 14 patients underwent a major and a minor resection, all with clear margins. Median diameter of solitary tumors or the larger tumor when multiple tumors occurred was 5.5 cm (range, 2.5-29 cm). Tumor encapsulation was present in 12 cases and absent in 16 cases. After informed consent, patients who had no evidence of residual or recurrent tumor on computed tomographic (CT) scan and no sign of liver failure 2 to 3 months after curative resection for HCC were included in the trial. Complete follow-up was obtained (median, 51 months; range, 5-93 months).

INTERVENTIONS

A 1110-MBq dose of (131)I-lipiodol was administered into the hepatic artery using the Seldinger technique. Patients were kept in a radio-protected room for 5 days. Postinjection radioactive whole scintiscan was performed at 5 days and an abdominal CT scan at 1 month after the injection. A second injection was performed in 16 patients 2 years later using the same protocol.

MAIN OUTCOME MEASURE

Procedure safety.

RESULTS

All patients experienced transient fever during the first 12 hours following injection. There were no noted adverse clinical effects or significant alteration in hepatic function due to the procedure or at immediate and late follow-up. The radioactive scan demonstrated an intense liver uptake, which was homogeneous in 19 cases and heterogeneous in 9. Mild detectable thyroid and lung uptake occurred in 50% of cases. No lipiodol liver fixation was observed on the 1-month CT scan. At the time of follow-up, 6 patients had died and 12 had developed recurrences, with 5 of the 6 deaths belonging to the recurrent group. Sixteen patients remained disease free. The median time to detected recurrence was 28 months (range, 12-62 months). Overall survival rates were 86% at 3 years and 65% at 5 years.

CONCLUSIONS

This pilot study failed to demonstrate any clinically significant adverse effect of adjuvant therapy by intra-arterial (131)I-lipiodol after curative liver resection for HCC. Long-term survival compares favorably with those undergoing only surgery and suggests a benefit in lowering tumor recurrence. A randomized, multicenter, prospective trial comparing patients treated with intra-arterial (131)I-lipiodol with a nontreated control group seems appropriate.

[Management of duodenal-pancreatic endocrine tumors]

Endocrine tumors of pancreas and duodenum have a common diagnostic and therapeutic approach. Surgery has a key role to play in the management of patients with such tumors. According to a particular patient, this role is to get under control a secretory syndrome which is refractory to medical therapy, to eradicate a malignant or a premalignant tumor, to produce cytoreduction by debulking, or to palliate complications due to massive regional extension of a malignant tumor.

Pancreaticoduodenectomy for metastatic ampullary and pancreatic tumors

BACKGROUND/AIMS

To report the clinical presentation, diagnosis and results of aggressive surgical management in patients with metastatic ampullary and pancreatic tumors.

METHODOLOGY

Twelve patients underwent pancreaticoduodenectomy for ampullary or pancreatic metastases from January 1, 1987, to June 30, 1998, in 2 institutions. The primary cancer was renal cell carcinoma (n = 5), melanoma (n = 2), venous leiomyosarcoma (n = 1), carcinoid tumor (n = 1), colon carcinoma (n = 1), breast carcinoma (n = 1) and small-cell lung carcinoma (n = 1). The mean interval between primary treatment and metachronous pancreatic metastasis was 88 months. In 3 cases, pancreatic metastases were synchronous with the primary tumor. The main symptoms were jaundice (n = 8) and upper gastrointestinal tract bleeding (n = 2). The principal investigations were computed tomography scan (n = 9), arteriography (n = 7), duodenoscopy (n = 6) and fine-needle aspiration (n = 4). A correct preoperative diagnosis was made for 8 patients.

RESULTS

In all cases, the pancreatic tumor was resected with intention to cure or provide useful palliation, using pancreaticoduodenectomy for isolated tumors (n = 11) or total pancreatectomy for multiple lesions (n = 1). Three out of 12 patents had positive lymph nodes, and the resection margin was free of disease in all cases. There was no postoperative mortality. Survival after pancreaticoduodenectomy averaged 26 months. Overall survival of patients undergoing pancreaticoduodenectomy was 35% at 2 years and 17% at 5 years. One patient is still alive more than 10 years after pancreaticoduodenectomy.

CONCLUSIONS

Pancreaticoduodenectomy can be performed safely, representing a suitable option for resection in patients with symptomatic or late isolated pancreatic metastases in the absence of widely metastatic disease. The best indications are solitary metastases from renal cell carcinoma, sarcoma and neuroendocrine tumors. However, there is no evidence of survival benefit after pancreaticoduodenectomy for synchronous tumors or metachronous tumors from melanoma or colon carcinoma.

Evaluation of the carcinogenic risks to humans associated with surgical implants and other foreign bodies - a report of an IARC Monographs Programme Meeting. International Agency for Research on Cancer

A meeting was held within the International Agency for Research on Cancer (IARC) Programme on the Evaluation of Carcinogenic Risks to Humans of surgical implants and other foreign bodies. This meeting report summarises the types of materials considered, their wear and degradation, their cancer epidemiology in both humans and other animals, the published experimental carcinogenicity data and selected data on their toxic, including genotoxic, effects. Evaluations resulting in a classification of Group 2B (possibly carcinogenic to humans) were reached for: (1) polymeric implants prepared as thin smooth films [with the exception of poly(glycolic acid)]; (2) metallic implants prepared as thin smooth films; and (3) implanted foreign bodies consisting of metallic cobalt, metallic nickel and a particular alloy powder consisting of 66-67% nickel, 13-16% chromium and 7% iron. Group 3 classifications (not classifiable as to their carcinogenicity to humans) were made for: (1) organic polymeric materials as a group; (2) orthopaedic implants of complex composition and cardiac pacemakers; (3) silicone breast implants; (4) dental materials; and (5) ceramic implants.

[Megaduodenum in chronic intestinal pseudo-obstruction: management by duodenectomy-duodenoplasty]

BACKGROUND

Surgical management of primitive chronic intestinal pseudo-obstruction involving the duodenum (megaduodenum) is an uncommon but still difficult problem.

PATIENTS AND METHODS

Six patients who experienced severe symptoms were managed by an original surgical procedure including partial duodenal resection and reconstruction of a duodenal tract using a large duodenal anastomosis (duodenectomy-duodenoplasty).

RESULTS

There was no postoperative complication. All preoperative symptoms completely regressed in all but one patient who had previously undergone a vagotomy and experienced transient early post-operative gastric stasis. With a median follow-up of 6 years (range 4-9), all patients had good functional results without any evidence of other motility disorders. The mean weight gain was 10 kg (range 7-15).

CONCLUSIONS

Duodenectomy-duodenoplasty is a safe procedure resulting in efficient symptom relief in patients suffering from megaduodenum.

Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial

PURPOSE

The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery.

PATIENTS AND METHODS

Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study.

RESULTS

A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27).

CONCLUSION

A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.

Peripheral cholangiocarcinoma: presentation, diagnosis, pathology and management

AIMS

To report the clinical presentation, diagnosis and results of aggressive surgical management in patients with intrahepatic cholangiocarcinoma.

METHODS

From February 1988 to June 1998, 21 patients underwent laparotomy with a 90% resectability rate (19 resections). The 19 liver resections included right trisegmentectomy in six patients, right lobectomy in five, wedge resection in four, left lobectomy in two, left trisegmentectomy in one and a lateral segmentectomy in one. Resection of the biliary confluence with reconstruction by a Roux en Y hepaticojejunostomy was performed in three patients.

RESULTS

Mild abdominal pain, weight loss and gastrointestinal disturbances were the most frequent clinical signs. Jaundice was present in only four patients. Pre-operative radiological investigations (abdominal ultrasound, computed tomography, arteriography) correlated with pathological findings in only 60% of cases. Pre-operative histological findings (fine-needle cytology, liver biopsy), available for 19 patients, did not always provide an accurate diagnosis. The mortality and morbidity rates were 5 and 47%, respectively. The median survival of resected patients was 18 months. Overall patient and tumour-free survival rates were 83 and 31% at 1 year, 33 and 16.5% at 2 years and 16.5 and 16.5% at 3 years in the resected group. Lymph-node spread, vascular invasion, positive margins and bilobar distribution were associated with a high recurrence rate and poor prognosis.

CONCLUSION

Despite the advanced stage of these tumours at presentation, patient survival can be improved by aggressive surgical resection. As intrahepatic cholangiocarcinoma usually develops in a non-cirrhotic liver, major hepatic resections to obtain disease-free margins can be performed with low mortality.

Cystadenomas and cystadenocarcinomas of the pancreas: a multiinstitutional retrospective study of 398 cases. French Surgical Association

OBJECTIVE

To review the features of patients with benign and malignant cystadenomas of the pancreas, focusing on preoperative diagnostic accuracy and long-term outcome, especially for nonoperated serous cystadenomas and resected cystadenocarcinomas.

SUMMARY BACKGROUND DATA

Serous cystadenomas (SCAs) are benign tumors. Mucinous cystic neoplasms should be resected because of the risk of malignant progression. A correct preoperative diagnosis of tumor type is based on morphologic criteria. Despite the high quality of recent imaging procedures, the diagnosis frequently remains uncertain. Invasive investigations such as endosonography and diagnostic aspiration of cystic fluid may be helpful, but their assessment is limited to small series. The management of typical SCA may require resection or observation. Survival after pancreatic resection seems better for cystadenocarcinomas (MCACs) than for ductal adenocarcinomas of the pancreas.

METHODS

Three hundred ninety-eight cases of cystadenomas of the pancreas were collected between 1984 and 1996 in 73 institutions of the French Surgical Association. Clinical presentation, radiologic evaluation, and surgical procedures were analyzed for 144 operated SCAs, 150 mucinous cystadenomas (MCAs), and 78 MCACs. The outcome of 372 operated patients and 26 nonoperated patients with SCA was analyzed.

RESULTS

Cystadenomas represented 76% of all primary pancreatic cystic tumors (398/522). An asymptomatic tumor was discovered in 32% of patients with SCA, 26% of those with MCA, and 13% of those with MCAC. The tumor was located in the head or uncinate process of the pancreas in 38% of those with SCA, 27% of those with MCA, and 49% of those with MCAC. A communication between the cyst and pancreatic duct was discovered in 0.6% of those with SCA, 6% of those with MCA, and 10% of those with MCAC. The main investigations were ultrasonography and computed tomography (94% for SCA, MCA, and MCAC), endosonography (34%, 28%, and 22% for SCA, MCA, and MCAC respectively), endoscopic retrograde cholangiopancreatography (16%, 14%, 22%), and cyst fluid analysis (22%, 31%, 35%). An accurate preoperative diagnosis of tumor type was proposed for 20% of those with SCA (144 cases), 30% of those with MCA, and 29% of those with MCAC. An atypical unilocular macrocyst was observed in 10% of SCA cases. The most common misdiagnosis for mucinous cystic tumors was pseudocyst (9% of MCAs, 15% of MCACs). Intraoperative frozen sections (126 cases) allowed a diagnosis according to definitive histologic examination in 50% of those with SCA and MCA and 62% of those with MCAC. For management, 93% of patients underwent surgery. Nonoperated patients (7%) had exclusively typical SCA. A complete cyst excision was performed in 94% of benign cystadenomas, with an operative mortality rate of 2% for SCA and 1.4% for MCA. Resection was possible in 74% of cases of MCAC. Mean follow-up of 26 patients with nonresected SCAs was 38 months, and no patients required surgery. For resected MCACs, the actuarial 5-year survival rate was 63%.

CONCLUSIONS

Spiral computed tomography is the examination of choice for a correct prediction of tumor type. Endosonography may be useful to detect the morphologic criteria of small tumors. Diagnostic aspiration of the cyst allows differentiation of the macrocystic form of SCA (10% of cases) and the unilocular type of mucinous cystic neoplasm from a pseudocyst. Surgical resection should be performed for symptomatic SCAs, all mucinous cystic neoplasms, and cystic tumors that are not clearly defined. Conservative management is wholly justified for a well-documented SCA with no symptoms. An extensive resection is warranted for MCAC because the 5-year survival rate may exceed 60%.

[Cephalic duodenopancreatectomy for endocrine tumor of the ampulla of Vater and of the minor papilla]

OBJECTIVES

Endocrine tumors of the ampulla of Vater and minor papilla are rare. This study describes the mode of presentation and evaluates the correlation between pathological features and prognosis.

PATIENTS

Between 1982 and 1998, 6 patients (3 M, 3 F, mean age: 47.6 years, range: 36-58) for whom a diagnosis of endocrine tumor of the ampulla of Vater or minor papilla was made between 1982 and 1998 after histological examination of an operative specimen of pancreaticoduodenectomy.

RESULTS

One patient was detected incidentally, two had a Zollinger-Ellison syndrome, two had pain and one had obstructive jaundice with pain. The tumor was located in the ampulla of Vater in 5 cases and at the minor papilla in 1 case. All patients underwent a pancreaticoduodenectomy, with histological examination showing tumor diameter varying from 5 to 40 mm and positive lymph nodes. Five patients had a well differentiated endocrine tumor and one a poorly differentiated tumor. All patients had positive Grimelius staining. The secretory profile analyzed by immunohistochemistry was heterogeneous. Median duration of follow-up was 51 months (range: 6 months-16 years) with all patients currently still alive. The patient with a poorly differentiated tumor had diffuse liver metastases, the others were disease-free.

CONCLUSION

This study demonstrates the frequency of metastatic spread to adjacent lymph nodes and the inconsistent secretory profiles of these tumors. Pancreaticoduodenectomy may offer long term disease-free survival in well differentiated tumors, and such histology may be useful in advising on prognosis.

[The Budd-Chiari syndrome (hepatic vein obstruction). The diagnostic and therapeutic management of acute and subacute forms]

EARLY DIAGNOSIS: The Budd-Chiari syndrome results from an obstruction of the suprahepatic venous drainage. The condition spontaneously evolves towards liver fibrosis and death. Early diagnosis is thus of prime importance to initiate adapted treatment promptly.

EXPLORATIONS

Color-coded and pulsed Doppler coupled with ultrasonography is the key to positive diagnosis. Magnetic resonance imaging may provide further precision. DECONGESTION OF THE LIVER: As the hepatic lesions are reversible, satisfactory drainage must be achieved as rapidly as possible, either by percutaneous puncture or surgery. The problem is to control the underlying hematology disease to prevent recurrent venous thrombosis, generally the cause of treatment failure. PREVENTIVE ANTICOAGULATION: Effective anticoagulation using low-molecular-weight heparin, which appears to be more adapted than standard heparin, must be achieved prior to any decongestion procedure. Long-term management requires anti-vitamin K therapy if the risk of thrombosis persists.

[Orthotopic liver transplantation from a living adult donor to an adult using the right hepatic lobe]

STUDY AIM

In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult.

PATIENTS AND METHODS

In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt.

RESULTS

The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intra-operatively the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation.

CONCLUSION

Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.

[Reoperation for recurrent cholangitis due to a defect in the hepatico-jejunal anastomosis]

We report three cases of postoperative recurrent cholangitis due to a defective hepaticojejunal anastomosis. Causal diseases were alveolar echinococcosis of the liver, alcoholic chronic pancreatitis, liver colorectal metastases. Clinical presentation included major cholestasis and cachexia. Imaging explorations showed that cholangitis was due to an inversion of the Roux-en-Y jejunal loop which had been disposed in a wrong position. Clinical improvement was remarkable after reoperation and replacement of the defective loop in the right position. This exceptional cause of postoperative cholangitis after Roux-en-Y hepaticojejunal anastomosis must be identified and treated by prompt restorative surgery.

[Solid pseudopapillary tumors of the pancreas. Pathology report of 13 cases]

OBJECTIVES

Solid pseudopapillary tumors of the pancreas are exceptional. The aims of our study were to reevaluate the mode of presentation of these tumors and to analyze the role of pathological examination in diagnostic assessment and prognostic evaluation.

PATIENTS

We report the clinical, radiological and pathological findings in a retrospective series of 13 patients in whom a diagnosis of solid pseudopapillary tumor of the pancreas was made between 1983 and 1997. There were 12 females (median age: 22.5 years) and one male, aged 73.

RESULTS

The tumor was discovered incidentally (3 cases) or because of nonspecific digestive symptoms (10 cases). Biological data were uninformative. The tumor was pancreatic in 12 cases and duodenal in 1. In all cases, imaging techniques showed an heterogeneous lesion with no or poor vascularization. A cystic component was identified in 4 cases. Surgical resection was performed in all cases. Pathological examination showed an encapsulated tumor in 8 cases, a non-encapsulated but well-limited lesion in 3 cases and an infiltrative tumor in 2 cases. At the time of diagnosis, multiple liver metastases were present in 1 case. Mean duration of follow-up was 24 months (range: 3-168). At last follow-up, all patients, including the patient with synchronous metastatic disease, were alive, without local recurrence.

CONCLUSION

Our study confirms that most cases of solid pseudopapillary tumors of the pancreas present with a suggestive clinical picture, including their occurrence in young women and their good prognosis after surgical resection. However, our results also underline the occurrence of cases presenting with unusual features, including old age, male sex, extra-pancreatic localization and malignant evolution. Histopathological examination is essential for the establishment of the diagnosis but morphological data are of little prognostic value.