The Application of Indocyanine Green to Evaluate Duodenal Perfusion in Pancreas Transplantation

In cases of suspected duodenal ischemia during pancreas transplantation, surgical decisions severely affect the outcome of the patient and the graft. The use of a nontoxic intravenous tracer, indocyanine green, allows the surgeon to evaluate the perfusion of tissues within seconds of injection. Its application to pancreas transplantation has not been reported previously.     

保留钩突部胰腺次全切除联合脾切除术治疗胰腺实性假乳头状瘤一例

1临床资料 患者女,55岁。因腹部胀痛不适20d,发现左季肋区包块10d于2012年3月26日收治入院。2012年3月5日患者于外院行子宫切除术。术后20d患者自觉腹上区胀满,无发热、腹痛、腰背痛等症状。当地医院B超检查：左季肋区实质性包块;CT检查：胰腺区占位性病变,胰腺癌可能性大。     

胰头占位性病变术前病理学诊断的必要性及指导性

胰头占位性病变行胰十二指肠切除术前是否需要病理学诊断一直是胰腺外科研究的热点问题.目前国内外指南与共识均指出:术前判断胰头占位性病变具有手术切除指征,则无需病理学诊断.但对于可能切除的胰腺癌拟行新辅助治疗的患者、不可切除的胰腺癌拟行放化疗的患者、剖腹探查发现胰头占位性病变不可切除拟行姑息性短路手术的患者必须有病理学诊断后方可施行手术.外科医师在做出临床决策时,应注重多学科团队模式的运用、与患者及家属充分沟通、正确与辩证地看待指南和共识,以有效提高对胰头占位性病变的诊断与治疗水平.     

Temperature profiles of different cooling methods in porcine pancreas procurement

Porcine islet xenotransplantation is a promising alternative to human islet allotransplantation. Porcine pancreas cooling needs to be optimized to reduce the warm ischemia time (WIT) following donation after cardiac death, which is associated with poorer islet isolation outcomes. This study examines the effect of four different cooling Methods on core porcine pancreas temperature (n = 24) and histopathology (n = 16). All Methods involved surface cooling with crushed ice and chilled irrigation. Method A, which is the standard for porcine pancreas procurement, used only surface cooling. Method B involved an intravascular flush with cold solution through the pancreas arterial system. Method C involved an intraductal infusion with cold solution through the major pancreatic duct, and Method D combined all three cooling Methods. Surface cooling alone (Method A) gradually decreased core pancreas temperature to <10 °C after 30 min. Using an intravascular flush (Method B) improved cooling during the entire duration of procurement, but incorporating an intraductal infusion (Method C) rapidly reduced core temperature 15–20 °C within the first 2 min of cooling. Combining all methods (Method D) was the most effective at rapidly reducing temperature and providing sustained cooling throughout the duration of procurement, although the recorded WIT was not different between Methods (P = 0.36). Histological scores were different between the cooling Methods (P = 0.02) and the worst with Method A. There were differences in histological scores between Methods A and C (P = 0.02) and Methods A and D (P = 0.02), but not between Methods C and D (P = 0.95), which may highlight the importance of early cooling using an intraductal infusion. In conclusion, surface cooling alone cannot rapidly cool large (porcine or human) pancreata. Additional cooling with an intravascular flush and intraductal infusion results in improved core porcine pancreas temperature profiles during procurement and histopathology scores. These data may also have implications on human pancreas procurement as use of an intraductal infusion is not common practice.     

Impact of adverse pancreatic injury at surgical procurement upon islet isolation outcome

The consequence of a pancreas injury during the procurement for islet isolation purpose is unknown. The goal of this work was to assess the injuries of the pancreata procured for islet isolation, and to determine their effect on the islet yield. Between January 2007 and October 2013, we prospectively documented every injury of the pancreata processed in our centre for islet isolation. Injuries involving the main duct were classified as major, the others as minor. Donors’ characteristics and islet yields were compared between the groups of injuries. A pancreas injury was identified in 42 of 452 pancreata received for islet isolation (9.3%). In 15 cases, the injury was major (3.3% of all pancreata). Although a minor injury did not affect the islet yield, a major injury was significantly associated with unfavourable outcomes (postpurification mean islet equivalent of 364 ± 181, 405 ± 190 and 230 ± 115 × 10³ for absence of injury, minor injury and major injury, respectively). A major injury was significantly more prevalent in lean and short donors. We recommend assessing the quality of the pancreas in the islet isolation centre before starting the isolation procedure. Each centre should determine its own policy based on its financial resources and on the wait list.     

胰腺实性假乳头状瘤的诊断和治疗（附28例报告）

目的 总结分析胰腺实性假乳头状瘤（SPTP）的临床特点和治疗效果,提高对该病的认识.方法 回顾性总结2000年10月至2013年3月间经手术和病理证实的28例SPTP病人的临床资料,并对其进行随访.结果 28例中,体检中无意发现肿物者12例,外伤后腹痛检出肿物者6例（均为未成年病人）,腹痛为首发症状者7例,复查意外发现者2例,肠梗阻为首发症状者1例.手术方式：肿物核除术5例;胰十二指肠切除术4例;胰尾切除术5例;胰体尾切除术3例;胰尾切除加脾脏切除术3例;病理活检2例;转移瘤切除1例;胰体切除、胰肠吻合术3例.位于胰头：8例,胰体：4例,胰尾：15例;其他腹壁转移：1例.表现为囊实混合性者22例.所有病人术后均未辅助放化疗治疗.28例病人中2例失访,26例获随访,随访时间为3个月至10年,平均15个月.4例复发,其中1例复发后3个月因合并心肺功能衰竭死亡,另3例经再次手术后治愈.余22例预后良好.本组5年生存率为96.4％.结论 SPTP无特异性临床表现,起病隐匿,CT及彩超对SPTP有诊断意义,手术切除肿瘤为SPTP的主要治疗方式,不经术前术后放疗和化疗,预后良好.     

Lymphoepithelial cysts and cystic lymphangiomas: Underrecognized benign cystic lesions of the pancreas

AIM: To identify their diagnostic and prognostic clinical characteristics in a large series.METHODS: Retrospective review of clinicopathologic and imaging characteristics of patients diagnosed with lymphoepithelial cysts and cystic lymphangiomas of the pancreas at Massachusetts General Hospital.RESULTS: Twelve patients were identified between 1/1/1997 and 8/1/2007. Their median age was 55.5 years(range 19-78 years), and 6 were females. The le-sion was incidentally discovered in half of the patients.Contrast enhanced computed tomography demonstrat-ed that the cysts had thin walls, without calcifications, pancreatic duct dilation or pancreatic parenchyma inva-sion. Endoscopic ultrasound with fine needle aspiration(EUS/FNA) confirmed the diagnosis of a lymphoepithe-lial cyst in 3 patients, one of whom was spared an op-eration and continues to do well after 6 years. Eleven patients had a resection: 3 pancreaticoduodenecto-mies, 7 distal pancreatectomies, and 1 enucleation. The median size of the cysts was 3 cm(range 2-20 cm). At a median follow-up of 57 mo no recurrences or other pancreas-related conditions occurred.CONCLUSION: Lymphoepithelial cysts and cystic lymphangiomas of the pancreas can be diagnosed with a combination of contrast-enhanced computed tomog-raphy scans and EUS/FNA. If the lesion is asymptom-atic, an operation might be avoided.     

Hypotonic duodenography — Too often performed but of too little value?

Hypotonic duodenography was compared with conventional barium examination in 68 patients (70 examinations) with clinically suggested or verified disease of the pancreas or duodenum. In 13 cases (18.5%) conventional examination demonstrated the duodenal anatomy better than hypotonic duodenography. In nine cases (13%) hypotonic duodenography was superior and in 48 cases (68.5%) both techniques were diagnostically equal.It is concluded that, in only a few cases, does hypotonic duodenography add any diagnostic information to that which can be obtained with properly performed conventional examination of the duodenum.     

Isogeneic or allogeneic transplantation of duct-ligated pancreas in streptozotocin diabetic mice.

Recovery from hyperglycaemia was observed in three different mouse hybrids that were made diabetic with streptozotocin, and then transplanted with pancreas from isogeneic donors whose pancreatic ducts were ligated over 8 weeks earlier. Recovery did not occur in recipients of allografts indicating that islets in ligated pancreas cannot be successfully transplanted across a major histocompatibility barrier. However, in lethally irradiated mice injected with allogeneic bone marrow (allogeneic radiation chimeras), subsequent transplantation of ligated pancreas from either isogeneic donors or allogeneic donors of the same strain as the bone marrow donor decreased blood glucose of diabetic recipients. Thus, irradiation and allogeneic bone marrow therapy allow subsequent allogeneic transplantation of functional islet tissue in diabetic mice. Observations on diabetic mice transplanted isogeneically with ligated pancreas suggest that recovery from hyperglycaemia was more consistent when grafts were placed subcutaneously rather than intraperitoneally and when hosts received ligated pancreas from three donors rather than one. Thus, the site and amount of tissue transplanted are important considerations in the transplantation of ligated pancreas. Persistence of endocrine beta-cells in ligated pancreas was required for recovery in grafted mice since diabetic hosts failed to recover when grafted with ligated pancreas obtained from alloxan or streptozotocin-treated, diabetic donors.