Cancer of the uncinate process of the pancreas:surgical anatomy and clinicopathological features

BACKGROUND:The clinicopathological features of uncinate process pancreatic cancer(UPPC) are poorly described.Furthermore the anatomy of the uncinate process and its division during surgery are central to pancreaticoduodenectomy for UPPC.We set out to describe the embryology and anatomy of the uncinate process and the clinicopathological features of UPPC.DATA SOURCES:All published case series of UPPC were reviewed and included in this review.RESULTS:The true incidence of UPPC is difficult to quantify,with th...     

Resection of the uncinate process of the pancreas due to a ganglioneuroma

A 33-year-old woman who presented with epigastric discomfort and diarrhea underwent an abdominal ultrasound （US）. This investigation and subsequent contrastenhanced computed tomography, magnetic resonance imaging and endoscopic US with fine needle aspiration （FNA） revealed a 40 mm well-circumscribed mass in the uncinate process of the pancreas. Findings were suggestive of a mucinous or solid-cystic pseudopapillary tumor of the pancreas, although other lesions such as a nonfunctioning neuroendocrine tumor could not be ruled out. FNA samples were negative for malignant cells, but of limited value due to poor cellularity. It was decided to surgically remove the tumor because malignancy could not be discounted. Multiple intraoperative biopsies were suggestive of mesenchymal tumor and consequently a conservative resection （uncinatectomy） was performed. The postoperative course was uneventful. The definitive diagnosis was ganglioneuroma. Immunocytochemistry showed positive staining with vimentin, S-100 protein, neurofilament and neuron-specific enolase. Ganglioneuroma is a rare benign tumor that can also present as a pancreatic tumor. Uncinatectomy is feasible, safe and a good surgical technique for the treatment of nonmalignant tumors located in the uncinate process of the pancreas.     

A case of neurofibroma located in the retroperitoneum involving the uncinate process of the pancreas

A case of solitary neurofibroma in the retroperitoneum involving the uncinate process of the pancreas, which has been reported in only one case in Japan and less than 20 cases in the world literature, is described. A 57-year-old male complained of back pain and microhematuria. Plain and enhanced abdominal computed tomography (CT) indicated an 8 × 6 cm hypovasular tumor located in the uncinate process. We initially assumed it to be a cancer of the pancreas. His physical examination and blood chemistry result were normal. Various diagnostic imaging methods however, disclosed a rare type of tumor. The tumor was resected by pancreaticoduodenectomy and histological examination revealed it to be neurofibroma.     

A case of neurofibroma located in the retroperitoneum involving the uncinate process of the pancreas

A case of solitary neurofibroma in the retroperitoneum involving the uncinate process of the pancreas, which has been reported in only one case in Japan and less than 20 cases in the world literature, is described. A 57-year-old male complained of back pain and microhematuria. Plain and enhanced abdominal computed tomography (CT) indicated an 8 x 6 cm hypovascular tumor located in the uncinate process. We initially assumed it to be a cancer of the pancreas. His physical examination and blood chemistry result were normal. Various diagnostic imaging methods however, disclosed a rare type of tumor. The tumor was resected by pancreaticoduodenectomy and histological examination revealed it to be neurofibroma.     

Ileal aberrant pancreas induces intussusception and gastrointestinal bleeding in an adult woman--case report.

Aberrant pancreas is a congenital anomaly. In surgical series, its incidence varied from 0.2 to 0.8%. About 70% of aberrant pancreas occur in the gastrointestinal tract. Eighty percent of them locate in the stomach and duodenum, and only 0.2% in the ileum. We report on a 25-year-old woman with ileal aberrant pancreas who suffered from ileal intussusception and recurrent gastrointestinal bleeding. The diagnosis was confirmed by surgery and histology. She is symptom-free after surgery.     

Efficiency of minimal oblique resection of the uncinate process during an anterior cervical discectomy and fusion

Hypertrophy of the uncinate process (UP) can cause radiculopathy. Minimal UP resection is considered to remove the lesion while minimizing the risk of complications. This study aimed to elucidate the surgical results of minimal oblique resection of the UP. This study is a retrospective review of about sixty segments in 34 patients who underwent anterior cervical discectomy and fusion (ACDF) with minimal oblique uncinectomy between 2016 and 2018. The cross-sectional area of the UP was measured pre- and postoperatively. The interspinous distance, segmental Cobb angle, subsidence, fusion rate, surgical time, estimated blood loss, and postoperative complications were evaluated. The mean resected areas of the UP were 17.4 ± 8.7 mm² (25.9%) on the right and 17.3 ± 11.2 mm² (26.2%) on the left. The difference in interspinous distance in flexion-extension was 7.1 ± 3.2 and 1.6 ± 0.6 mm pre- and postoperatively, respectively (P = .000). The fusion rate after ACDF was 91.7% when measured according to segment (55/60) and 91.2% when measured according to patients (31/34). The difference in the segmental Cobb angle in flexion-extension was 8.3 ± 6.2° and 1.9 ± 0.3° pre and postoperatively, respectively (P = .000). Subsidence occurred in 4 (11.8%) patients and 5 (8.3%) segments. The average surgical time per segment was 68.8 ± 9.3 minute, and the estimated blood loss was 48.5 ± 25.0 mL. Postoperative complications comprised 1 case each of neck swelling, wound infection, pneumonia, and gastrointestinal bleeding. Our findings therefore revealed that minimal oblique uncinectomy during an ACDF can maintain the stability of the uncovertebral joint while sufficiently decompressing the neural foramen.     

Is the rat pancreas an appropriate model of the human pancreas?

During my lifetime in pancreatic research, rat and mouse have largely replaced dog and cat in experimental studies. However, as this review clearly demonstrates, the anatomy, physiology and molecular cell biology of the rat pancreas (and also probably the mouse pancreas) differ substantially from those in humans. Indeed, they differ more in rat/mouse than any other common laboratory species. These differences may be irrelevant if one is using the pancreas as a generic model in which to study, say, acinar cell exocytosis or signalling. But if one is interested in more specific aspects of human pancreatic function, especially ductal function, in health and disease, in my opinion the simple answer to the question posed by the title of this article is no: other species are more appropriate.     

Coronary artery disease: an inflammatory or infectious process

It is well accepted that coronary artery disease is linked to an inflammatory process. It is unknown which agents may cause or accelerate coronary artery disease. An inflammation of the vessel wall may be caused by a number of mechanisms such as accumulation of glycosylated proteins in diabetic patients, oxidised LDL in patients with hypercholesterolemia or infectious agents. Among the possible infectious agents Chlamydia pneumoniae is the most likely microorganism involved in atherosclerosis. The arguments in favour of Chlamydia pneumoniae result from seroepidemiologic studies and from detection of chlamydial DNA in atherosclerotic plaques by polymerase chain reaction (PCR). In addition this microorganism is the only one that could be isolated from atherosclerotic tissue. This review summarises the present understanding of the role of an inflammatory process in the development or progression of coronary artery disease.     

Modification in the technique of pancreaticoduodenectomy: supracolic division of jejunum to facilitate uncinate process dissection

Pancreaticoduodenectomy remains the recommended procedure for periampullary and pancreatic head tumors. The dissection of the uncinate process from the superior mesenteric vessels is a key step in this surgery. We describe a modification in the existing practice of infracolic division of the jejunum in order to facilitate this step. In this modification, the duodenojejunal (DJ) flexure and the proximal jejunum are delivered into the supracolic compartment and then the jejunum is divided. This exposes the uncinate process completely and facilitates the separation from the Superior Mesenteric Artery (SMA) and the Superior Mesenteric Vein (SMV). We have successfully employed this modified technique for 33 resections since February 2004. This modification of dividing the jejunum in the supracolic compartment is based on sound anatomic and embryologic grounds. It helps in aligning the uncinate process with the jejunal mesentery thereby making the dissection of uncinate process from the superior mesenteric vessels safe and complete.     

Variant Preexcitation Syndrome: A True Nodoventricular Mahaim Fiber or an Accessory Atrioventricular Pathway with Decremental Properties?

WPW Variant. Introduction: The differentiation between a nodoventricular fiber and an accessory atrioventricular (AV) pathway with long conduction times and decremental properties could he very difficult even at detailed electrophysiologic study.
Methods and Results: A 20-year-old male with a history of a wide QRS tachycardia underwent electrophysiologic study. Baseline intervals were normal. There was evidence of dual AV pathways, and a sudden increase in AH interval was associated with the emergence of a delta wave. The atrio-delta interval showed a progressive prolongation. The preexcited QRS complex was typical of a posteroseptal pathway, and the earliest ventricular activation site was recorded at the posteroseptal region. Retrograde conduction was exclusively over the normal conduction system. During ventricular extrastimulation, a sudden increase in HA interval was associated with anterograde conduction over the accessory pathway. The intervals between the stimulus artifact and the onset of the delta wave during atrial pacing from two atrial sites (S-Delta) were compared with those between the retrograde atrial electrogram on the His channel and the onset of the delta wave during ventricular pacing (A2_HB-Delta). When pacing from the proximal coronary sinus, the shortest S-Delta interval did become shorter than the longest A2HK-Delta interval (155 vs 170 msec).
Conclusion: The finding that the S-Delta interval could become shorter than the A2_HB-Delta interval provides strong evidence that this accessory pathway was not connected to the AV node hut arose directly from the atrial tissue of the posteroseptal region.     

Ductal branch-oriented pancreatic resection for an intraductal papillary mucinous neoplasm in the uncinate process that caused recurrent acute pancreatitis: a case report of successful treatment

Acute pancreatitis reportedly occurs in about 15 % of cases of branch duct (BD)-intraductal papillary mucinous neoplasms (IPMNs), with two-thirds of BD-IPMNs being located in the head or uncinate process of the pancreas. However, the surgical indications and optimal treatment methods for BD-IPMNs have not been established. A 59-year-old Japanese male with epigastralgia was admitted to our hospital. A multidetector row computed tomography (MDCT) scan disclosed grade I acute pancreatitis. Magnetic resonance cholangiopancreatography disclosed a 1.5-cm BD-IPMN in the uncinate process. Two months after discharge, the epigastralgia recurred, and MDCT again revealed grade I pancreatitis. Due to the repeated episodes of pancreatitis, we performed ductal branch-oriented pancreatic resection. To detect the inferior branch of the Wirsung duct and avoid the development of a pancreatic fistula, we injected indigo carmine into the tumor which confirmed ligation of the inferior branch. Histopathologically, the tumor proved to be an adenoma. The postoperative course was uneventful in both the short- and long-term follow-up and, to date, there has been no recurrence of pancreatitis, or diabetes mellitus during the 6 years since pancreatectomy. This procedure is one of the methods that can be used for the successful resection of a BD-IPMN in the uncinate process that caused recurrent acute pancreatitis.     

Intestinal autotransplantation for adenocarcinoma of pancreas involving the mesenteric root: our experience and literature review

Ductal adenocarcinoma of pancreas represents one of the most aggressive tumor as demonstrated by 3- and 5-year survival rates. Involvement of mesenteric pedicle affects both the possibility to perform a tumor-free margin resection and accounts for most exploratory laparotomy for locally advanced disease. The ex vivo resection of the tumor (autotransplantation) after total exenteration and perfusion of the intestine might have a role to overcome some technical obstacles. So far, only 5 patients have been reported to have undergone small-bowel autotransplantation for tumor involving the mesenteric root. We describe 2 cases of adenocarcinoma of pancreas involving mesenteric root treated by small-bowel autotransplantation. Both patients survived from the procedure and were discharged home on postoperative days 16 and 29, respectively. The tumor was resected with free surgical margins, and both patients underwent adjuvant treatment. Intestinal autotransplantation can represent a significant technical advance for increasing the resectability rate and, ultimately, the survival rate for advanced adenocarcinoma of the pancreas in highly selected patients.