BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA

Background:

Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis.

Aim:

To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil.

Methods:

Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment.

Results:

Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely.

Conclusions:

It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial

BACKGROUND AND STUDY AIMS

 Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % - 90 %). However, there is no study comparing these 2 techniques.

PATIENTS AND METHODS

 From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods.

RESULTS

 The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P  > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, - 25.2 min (CI95 % - 12.48 to - 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events.

CONCLUSION

 Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.

The influence of transforming growth factor-α, cyclooxygenase-2, matrix metalloproteinase (MMP)-7, MMP-9 and CXCR4 proteins involved in epithelial-mesenchymal transition on overall survival of patients with gastric cancer

AIMS

Determination of prognostic parameters that are predictive of survival of gastric cancer (GC) may allow better identification of patients who could benefit from current chemotherapy regimens. To assess the correlation between tumour progression and epithelial-mesenchymal transition (EMT), we assayed the expression levels of selected molecules involved in EMT [CD44, transforming growth factor (TGF)-α, cyclooxygenase-2 (COX-2), matrix metalloproteinase (MMP)-7, MMP-9 and C-X-C chemokine receptor (CXCR4)], and correlated these with overall patient survival (OS) and disease stage.

METHODS AND RESULTS

Medical records and pathological biopsy results of 137 patients with GC were evaluated retrospectively. Spearman's correlation analysis showed that expression of CXCR4 was correlated significantly with the expression of all other proteins studied. In contrast, COX-2 expression correlated significantly with the expression of only MMP-7 (P = 0.011), MMP-9 (P = 0.015) and CXCR4 (P = 0.013). We observed significant negative correlations between OS and the expression of TGF-α (P = 0.017), COX-2 (P < 0.001), CXCR4 (P = 0.010), MMP-7 (P = 0.020) and MMP-9 (P = 0.015). On multivariate analysis, only COX-2 was an independent prognostic factor for OS [hazard ratio (HR) = 3.34; 95% confidence interval (CI): 1.43-9.75; P = 0.002).

CONCLUSIONS

COX-2, TGF-α, MMP-7, MMP-9 and CXCR4 are associated with poor OS in gastric cancer.

The interaction between N-category and N-ratio as a new tool to improve lymph node metastasis staging in gastric cancer: results of a single cancer center in Brazil

BACKGROUND

Depth of tumor invasion (T-category) and the number of metastatic lymph nodes (N-category) are the most important prognostic factors in patients with gastric cancer. Recently, the ratio between metastatic and dissected lymph nodes (N-ratio) has been established as one. The aim of this study is to evaluate the impact of N-ratio and its interaction with N-category as a prognostic factor in gastric cancer.

METHODS

This was a retrospective study in which we reviewed clinical and pathological data of 165 patients who had undergone curative surgery at our institution through a 9-year period. The exclusion criteria included metastases, gastric stump tumors and gastrectomy with less than 15 lymph nodes dissected.

RESULTS

The median age of the patients was 63 years and most of them were male. Total gastrectomy was the most common procedure and 92.1% of the patients had a D2-lymphadenectomy. Their 5-year overall survival was 57.7%. T-category, N-category, extended gastrectomy, and N-ratio were prognostic factors in overall and disease-free survival in accordance with univariate analysis. In accordance with TNM staging, N1 patients who have had NR1 had 5-year survival in 75.5% whereas in the NR2 group only 33% of the cases had 5-year survival. In the multivariate analysis, the interaction between N-category and N-ratio was an independent prognostic factor.

CONCLUSION

Our findings confirmed the role of N-ratio as prognostic factor of survival in patients with gastric cancer surgically treated with at least 15 lymph nodes dissected. The relationship between N-category and N-ratio is a better predictor than lymph node metastasis staging.

Selected patients with metastatic melanoma may benefit from liver resection

BACKGROUND

In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma.

METHODS

Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities.

RESULTS

Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively.

CONCLUSIONS

Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Modified pharyngogastrostomy by a stapler technique

Pharyngolaryngoesophagectomy is the gold standard treatment for the majority of larynx, pharynx and cervical esophagus advanced tumours. Reconstruction of these pharyngoesophageal defects is complex, and implicates additional time, morbity and mortality to the procedure. Gastric pull up and pharyngogastrostomy with hand sewing technique is the commonest way of doing it. The authors describe a modified technique to execute it using a stapler device.

Prognostic score in gastric cancer: the importance of a conjoint analysis of clinical, pathologic, and therapeutic factors

BACKGROUND

This study was designed to establish a prognostic score for gastric cancer that takes into account factors related to the tumor, the patient, and the treatment.

METHODS

Two hundred thirty patients with gastric adenocarcinoma admitted t o the Department of Abdominal Surgery at Hospital do Câncer A. C. Camargo (São Paulo) and treated by gastrectomy from January 1992 until December 1996 were included in this retrospective cohort. The prognostic score was created according to the variables identified in the multivariate analysis and by using the regression coefficients generated by the Cox regression.

RESULTS

The 5-year overall survival rate was 44.5%. The final multivariate model identified six variables with a significant and independent effect on survival: sex, weight loss, lymphocyte count, tumor-node-metastasis staging, lymphadenectomy, and lymph node ratio. Patients were divided into four groups according to their scores, as follows: group 1, 0 to 3.0; group 2, 3.5 to 5.5; group 3, 6.0 to 8.5; and group 4, 9.0 to 14.0. The 5-year survival rates were 91.5%, 49.3%, 20.3%, and .0% for the score groups 1, 2, 3, and 4, respectively (P<.001). The score was superior in the assessment of prognosis when compared with tumor-node-metastasis staging alone.

CONCLUSIONS

It is possible to create a prognostic score that simultaneously includes factors related to the tumor, patient, and treatment, thus generating a more effective system in predicting the prognosis than the morphology-based staging systems.

Acute pancreatitis associated with neuroendocrine tumor of the pancreas

CONTEXT

Endocrine tumors are a less commonly known cause of acute pancreatitis. This report presents the case of a patient who have had acute pancreatitis secondary to a pancreatic endocrine neoplasm. The majority of the cases previously reported were non-functioning tumors and the pancreatitis tended to be mild. Moreover, the majority of the tumors were diagnosed in advanced stages, hindering curative treatment.

CASE REPORT

A 31-year-old female patient presented with epigastric pain and a history of recurrent acute pancreatitis. Preoperative imaging investigation showed a dilation of the distal portion of the main pancreatic duct and intra-operative ultrasound demonstrated a mild stricture of the main pancreatic duct at the body of the pancreas. Frozen-section examination revealed a malignant neoplasm, subsequently identified as a neuroendocrine carcinoma, and a distal pancreatectomy with splenectomy was performed. Acute pancreatitis was an early symptom in this patient who underwent a hopefully curative resection.

CONCLUSION

The authors conclude that, in patients with acute pancreatitis of unknown origin, the possibility of a non-functioning neuroendocrine tumor should be investigated.

Serous oligocystic adenoma of the pancreas

Cystic neoplasms of the pancreas are uncommon lesions but are becoming increasingly prevalent. Herein we report a case of an oligolocular cystic lesion in the head of the pancreas in a young female that had undergone a cystenteroanastomosis 10 years ago. She underwent a duodenopancreatectomy with an uneventful recovery. The histology showed a serous oligocystic adenoma of the pancreas and the immunohistochemistry study confirmed the diagnosis. There is no sign of recurrence after the surgery. The role of pre-operative diagnosis based on tomographic, echoendoscopy and fine needle aspiration are discussed.

Pancreatic head tumors with portal vein involvement: an alternative surgical approach

BACKGROUND/AIMS

One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion.

METHODOLOGY

Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step.

RESULTS

Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality.

CONCLUSIONS

This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience

BACKGROUND/AIMS

The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied.

METHODOLOGY

Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied.

RESULTS

Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%).

CONCLUSIONS

Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

[Laparoscopic treatment of common bile duct lithiasis]

With the advances of videolaparoscopic surgery, this approach had become the treatment of choice for cholelithiasis. However, about 5% to 10% may present common bile duct lithiasis. Most surgeons have still difficulties to deal with this situation and do prefer resolve with open surgery or with further endoscopic approach. We present a case of a 60-year-old man, with 18 months history of right upper quadrant pain, weight loss and jaundice. He was referred with diagnostic of pancreatic cancer. Laboratory investigation showed increased bilirubin (10 mg/dL), alkaline phosphatase and GGT. Abdominal ultrasound showed atrophic gallbladder with dilated intra and extrahepatic biliary tree. Computerized tomography scan disclosed enlarged biliary tree with 3 cm stone in the distal common bile duct. The patient underwent a laparoscopic cholecystectomy followed by choledochotomy and retrieval of the large stone. A latero-lateral choledochoduodenum anastomosis was then performed to decompress the biliary tree. The patient had an uneventful recovery being discharged at the 6th postoperative day. Laparoscopic management of choledocholithiasis is feasible in many patients, specially those with dilated biliary tree. The retrieval of stones may be followed by biliary drainage with T-tube. In some elderly patients with chronically dilated common bile duct, as in the present case, a choledochoduodenal anastomosis is the procedure of choice.

Alternative technique of laparoscopic hepaticojejunostomy for advanced pancreatic head cancer

Only 20% of patients with pancreatic cancer can undergo curative resection. Therefore, palliative treatment of pancreatic cancer assumes the utmost clinical importance. The aim of the palliative treatment of pancreatic head carcinoma is to relieve the jaundice and/or duodenal obstruction. Endoscopic or transparietal decompression of the obstructed bile duct can be accomplished in most cases, but the durability of these techniques is not as great as that of a surgically created bypass. On the other hand, hepaticojejunostomy carries higher morbidity and mortality rates than the former nonsurgical methods. In order to promote long lasting palliation with low morbidity and mortality rates, minimally invasive techniques of biliary and gastric bypass have been described. However, laparoscopic Roux-en-Y hepaticojejunostomy seems to be a complex surgical procedure. With an aim to simplify the construction of a laparoscopic hepaticojejunostomy, the authors suggest an alternative technique.

Hepatic adenoma and focal nodular hyperplasia: differential diagnosis and treatment

The diagnosis of benign hepatic tumors as hepatic adenoma (HA) and focal nodular hyperplasia (FNH) remains a challenge for clinicians and surgeons. The importance of differentiating between these lesions is based on the fact that HA must be surgically resected and FNH can be only observed. A series of 23 female patients with benign liver tumors (13 FNH, 10 HA) were evaluated, and a radiologic diagnostic algorithm was employed with the aim of establishing preoperative criteria for the differential diagnosis. All patients were submitted to surgical biopsy or hepatic resection to confirm the diagnosis. Based only on clinical and laboratory data, distinction was not possible. According to the investigative algorithm, the diagnosis was correct in 82.6% of the cases; but even with the development of imaging methods, which were used in combination, the differentiation was not possible in four patients. For FNH cases scintigraphy presented a sensitivity of 38.4% and specificity of 100%, whereas for HA the sensitivity reached 60% and specificity 85.7%. Magnetic resonance imaging, employed when scintigraphic findings were not typical, presented sensitivities of 71.4% and 80% and specificities of 100% and 100% for FNH and HA, respectively. Preoperative diagnosis of FNH was possible in 10 of 13 (76.9%) patients and was confirmed by histology in all of them. In one case, FNH was misdiagnosed as HA. The diagnosis of HA was possible in 9 of 10 (90%) adenoma cases. Surgical biopsy remains the best method for the differential diagnosis between HA and FNH and must be performed in all doubtful cases. Surgical resection is the treatment of choice for all patients with adenoma and can be performed safely. With the evolution of imaging methods it seems that the preoperative diagnosis of FNH may be considered reliable, thereby avoiding unnecessary surgical resection.

Carcinoid tumor of the gallbladder

The carcinoid tumor is a relatively rare type of endocrine tumor, which arises mainly in the gastrointestinal tract. Primary gallbladder and biliary duct system carcinoids comprise less than 1% of all carcinoid tumors arising from any tissue or organ in the body. We describe a case of carcinoid tumor of the gallbladder in a 39-year-old man. There have been only 32 cases described in the literature.

An alternative technique in the treatment of celiac axis stenosis diagnosed during pancreaticoduodenectomy

Celiac compression is usually a benign condition, but when surgery necessitates division of collaterals from the superior mesenteric artery, it may cause life-threatening celiac organ ischemia. Celiac axis obstruction is found in 12.5% to 49.7% of patients during abdominal angiography. In such patients, the arterial blood supply to the stomach, spleen, and liver is sustained through extraordinarily well-developed pathways in the pancreas. Though collateral pathways may be sacrificed during pancreaticoduodenectomy, only a small proportion of patients develop hepatic, gastric and splenic ischemia during the procedure. If the appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery, as recommended by Bull et al., should precede its ligation. The hepatic arteries are palpated before and after the test occlusion. In the occasional patient in whom the pulse diminishes during occlusion or if there is evidence of upper abdominal visceral ischemia, revascularization of the celiac circulation may be required. Reestablishment of the celiac circulation may be accomplished by the use of a vein graft between the aorta and the celiac tributaries. This article describes an alternative technique for revascularization of the celiac circulation without the use of a venous graft.

[Laparoscopic cholecystectomy in a patient with sickle-cell anemia]

Laparoscopic cholecystectomy has recently become a popular alternative to traditional laparotomy and cholecystectomy in the management of patients with gallbladder disease. Elective surgical treatment of cholelithiasis in patients with sickle cell anemia has been followed by frequent postoperative complications. We present a case of elective laparoscopic cholecystectomy in a patient with sickle cell anemia followed by severe postoperative complications related to the hematological disease.

[Duodenal duplication in adult simulating pancreas pseudocyst]

An adult patient with clinical and radiologic evidence of pancreas pseudocyst was undergone at laparotomy and a diagnosis of duodenal duplication was made. Due to the rarity of this case, a review of the literature is presented and the authors discuss the treatment of duodenal duplication.

Pyogenic liver abscess: the role of surgical treatment

MATERIALS AND METHODS

We present an analysis of 48 patients with pyogenic liver abscess (PLA) that were treated according to a protocol between 1975 and 1993. In this period, 35 patients with PLA were treated by surgical drainage (SD). The indication for surgical treatment of the abscess were patients in septic conditions, underlying intra-abdominal surgical disease and the failure/contraindication of other therapeutic methods. Thirty-one patients were submitted to surgical treatment as the initial procedure and four patients unsuccessfully treated by percutaneous drainage, underwent SD.

RESULTS

The surgical approach was indicated in patients with severe disease and presented 91.5% of good results, and a mortality rate of 8.5%.

CONCLUSIONS

These results suggest that surgical treatment is a good alternative as a first step not only for the treatment of the primary cause of the abscess but also in septic patients with severe disease where a delay in adequate drainage, frequent in percutaneous management, can lead to high morbidity and mortality rates.

[Early adenocarcinoma of the duodenum--report of a case]

The early duodenal carcinoma is a very rare type of neoplasia, usually asymptomatic, its surgical treatment remains a controverse issue. In the present case an early duodenal carcinoma was incidentally found at the pathological specimen after a gastrectomy with BII reconstruction for a gastric adenoma unressectable by endoscopy. The patient is now alive for two years, without evidence of recurrence on follow-up.

[Biliary fistula after elective conventional cholecystectomy]

The use or not of drainage after elective cholecystectomy has been recently studied, and we will discuss the real incidence of the subhepatic biliary collection and its clinical significance. In this sense, we studied 20 patients with a mean age of 45 years (4 male and 16 female), submitted to elective cholecystectomy according to selective techniques patterned by our group, where we realized ligature of all vessels of the gallbladder bed, and subhepatic drainage. These patients receibed 99 mTc-DISIDA at the moment we closed the abdomen, and in a period of 24 and 48 hours we studied its presence in the subhepatic bed and in the drainage material. All the patients had not post-operative complications and none biliary drainage or subhepatic collection scanned. We concluded that using our preconized techniques, the subhepatic drainage is unnecessary after elective cholecystectomy.

[Distal pancreatectomy with conservation of the spleen]

Conventional resection of the body and tail of the pancreas usually involves splenectomy. There are evidence that spleen removal can lead to septic and hematological complications and should, therefore, be avoided when possible. Distal pancreatectomy with spleen conservation has been described by specialized centers with good results. This report describes our experience in 8 cases with conservation of the spleen during the resection of the body and tail of the pancreas. The technique has been applied in patients with pancreatic neuroendocrine tumors (n = 4), cystic tumors (n = 3) and cystic-papillary tumor (n = 1) with no complications and good late results in all cases.

[Results of conventional cholecystectomy. Experience in a university hospital]

The experience with open cholecystectomy in an university affiliated hospital is documented in this report. We studied retrospectively 221 patients operated between 1987 and 1992, type of surgery, morbidity and mortality were analyzed. There were 171 (77.3%) cholecystectomy alone and 50 (22.7%) cholecystectomy with other biliary surgery (BS). Pulmonary, urinary and wound complications were the most common. Overall incidence of complications was 7.2%. For patients with cholecystectomy alone morbidity was 3.5% and for patients with BS morbidity was 20% (p < 0.002). There were no mortality in this group of patients.

[Effect of omeprazole administration on pancreatic content of enzymes in rats]

Gastric chloride acid plays an important role in pancreatic enzyme synthesis and secretion, mediated by cholecystokinin released in the duodenum. This study was designed to evaluate the influence of gastric acid suppression by omeprazole on pancreatic enzyme content. Eighteen male Wistar rats (180-220 g) were divided in two groups: I--control and II--omeprazole. Animals received by intraduodenal catheter 3 doses of 0.5 ml saline solution (NaCl 0.9%)--Group I or 5 mumol/Kg of omeprazole solution--Group II at 24 h intervals. All animals, after an overnight fasting period, were killed 3 h after the last dose. Serum amylase and pancreatic tissue content of protein, trypsinogen, elastase, lipase and phospholipase A2 were determinated. Omeprazole treated animals (group II) showed statistically significant lower levels of serum amylase and pancreatic trypsinogen content (P < 0.05). We believe that this effect is related with acid secretion suppression by omeprazole and that it may be mediated by cholecystokinin.

[Bouveret's syndrome: a case report]

A patient with duodenal obstruction resulting from passage of a gallstone through the wall of the gallbladder into the duodenum is reported. The patient was successfully treated by removal of the gallstone. A review of literature concerning the diagnosis, treatment and etiopathogenesis is presented.

[Cystic neoplasm diagnosed as pancreatic pseudocyst: report of 5 cases and review of the literature]

The majority of cystic lesions of the pancreas are pseudocysts. Nine to thirteen per cent of pancreatic cyst are neoplastic, benign or malignant. Failure to recognize neoplastic nature of a cyst leads to an improper management. The authors present five cases of cystic tumors mistaken for pancreatic pseudocysts, including three mucinous cystadenomas and two mucinous cystadenocarcinomas. Four were drained by cystojejunostomy and one cystogastrostomy. One patient with no metastases at first operation had metastatic spread at reoperation. In the other four cases, subsequent resection was possible and probably curative. Review of the literature and guidelines are given for the purpose of differential diagnosis between theses entities.

[Simplified model of induction of experimental acute pancreatitis with a supra-maximal dose of cerulein]

The study was performed to compare an usual method of induction of acute experimental pancreatitis with a simplified, easier and faster induction through a subcutaneous and intravenous injection of cerulein, with good reproducibility as compared to the literature. Four groups were studied. In the group I, continuous three hour intravenous injection of 15 micrograms/Kg of cerulein, was given. Group II was a control group with saline infusion. Group III received a subcutaneous injection of 20 micrograms/Kg and an intravenous injection of 20 micrograms/Kg of cerulein one hour later. Group IV was the control group with saline. The results of biochemical measurements, such as tecidual trypsinogen, chimotrypsinogen, proelastase, cathepsin and serum amylase, showed no difference between the two methods. Histologic study revealed edematous pancreatitis in group I and III, with moderate acinar necrose in group III. These results suggest that the proposed simplified method induces enough acute and edematous pancreatitis to allow studies in physiopathology and therapeutics.

[Cystic neoplasm of the pancreas: analysis of 24 cases]

Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. We report 24 patients with cystic tumors of the pancreas, including twelve patients with serous cystadenoma, ten with mucinous cystadenoma and two patients with mucinous cystadenocarcinoma. Twenty-two patients were women and two were man. The median age of patients was 53.5 years (range, 21 to 80 years). Mild abdominal pain was the main symptom; in 71% of patients and weight loss in 29% of patients. The lesions were incidental findings 8% of patients. The mean size of the cysts was 7.8 cm (range, 2.3 to 15cm). Eleven cystic neoplasms were located in the head, three in the neck, five in the body, two in the tail of pancreas and three in the body and tail. All patients underwent surgical exploration. There was no perioperative mortality. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type.

[Duodenal perforation following endoscopic papillotomy: report of 3 cases]

Duodenal perforation is a rare complication of endoscopic sphincterotomy and its treatment is controversial. The authors report three cases of duodenal perforation by endoscopic sphincterotomy. In two cases with history of a previous biliary infection, surgical treatment had to been performed because of a peripancreatic abscess.