Recurrence of cancer in the heterotopically auto-transplanted caudal pancreas

We performed segmental auto-transplantation of the caudal pancreas to the groin after total pancreatectomy and sufficiently preserved the endocrine functions of the pancreas in 20 patients with advanced pancreatic head cancer. Nineteen patients have died, and autopsies were permitted for 18 of these 19 patients. The autopsies were performed 49–922 (mean 404) days after surgery. Cancer cells were microscopically noted in the transplanted pancreas in 2 of 2 patients in whom cancer cells had been noted on the transected plane of the pancreas in the postoperative examination. Cancer cells were also noted in the transplanted pancreas in 10 of 16 patients whose transected plane had been free of cancer cells in the postoperative examination. In the surviving patient, the transplanted pancreas was removed 39 months after surgery, due to recurrence. Thus, the recurrence rate was 11/17 (64.7%). The site of recurrence was the proximal portion of the graft in 10 of these 11 patients. It is suggested that there were some precursor cells left in the transected portion of the transplanted pancreas which subsequently developed into cancer cells.     

Pancreatitis and pancreas divisum: aetiological and surgical considerations

It has been suggested that acute pancreatitis occurs more commonly in patients with pancreas divisum and that these patients may respond to surgery aimed at improving pancreatic ductal drainage. We have studied the incidence of pancreas divisum in patients referred for endoscopic retrograde cholangio pancreatography (ERCP) and the results of surgical sphincteroplasty in a separate series of such patients. Twenty-three patients with pancreas divisum were identified among 336 successful pancreatograms (Group A), an incidence of 6.8%. The incidence of pancreas divisum in patients having ERCP for documented pancreatitis was 13% (11 of 86) compared with 4.8% (12 of 250) in those having ERCP for other indications. This difference was statistically significant (P less than 0.05). However, pancreas divisum was not the sole risk factor for pancreatitis in the majority of our patients; most also had one of the commonly recognized causes for their pancreatitis. There is dispute about the indications for surgery in patients with recurrent acute pancreatitis and pancreas divisum, but without any other risk factor. We have reviewed the results of operations on 13 patients with pancreas divisum (Group B) treated in four different hospitals. Surgical sphincteroplasty was carried out on 10 patients with documented pancreatitis and seven of these had good results. Three patients who had operations for pain without documented pancreatitis were not improved.     

Pancreatitis associated with pancreas divisum: results of surgical intervention

The embryologic defect that results when the ventral and dorsal anlages of the pancreas do not fuse has been referred to as pancreas divisum. The patients who present with recurrent pancreatitis or pancreatitis-like pain in association with pancreas divisum should be investigated to determine the presence of minor papilla stenosis. In the present study of 11 patients, 9 became asymptomatic with surgical decompression of the dorsal pancreatic duct. Two surgical failures were related to wrong diagnosis and restenosis of the sphincteroplasty. A delay in the clearance of dye from the dorsal pancreatic duct after endoscopic retrograde cholangiopancreatography was utilized to determine minor papilla stenosis. In the future, secretin ultrasound tests should prove of value in assessing minor papilla stenosis. Once the diagnosis is made, sphincteroplasty of the minor papilla is the most logical procedure because of the good results obtained. In the present study, pancreaticojejunostomy provided good duct decompression as well.     

Pancreatitis because of foregut duplication cyst of the pancreas treated by laparoscopic resection

We report a rare case of a foregut duplication cyst of the pancreas containing respiratory epithelium in a healthy adolescent male who presented with recurrent abdominal pain secondary to pancreatitis. The abnormality was revealed on computed tomography performed to evaluate severe abdominal pain radiating to the back. Further imaging (ultrasound and magnetic resonance imaging) confirmed that the lesion was a cyst with no apparent pancreatic ductal communication. Elective laparoscopic resection of the cyst was performed with complete resolution of the patient's symptoms.     

Pancreatitis necessitating urinary undiversion in a bladder-drained pancreas transplant.

After successful combined pancreaticoduodeno-renal transplant in an insulin-dependent diabetic, recurrent episodes of transplant pancreatitis were treated with Foley catheter drainage. The apparent cause of pancreatitis was increased pressure on the pancreatic duct due to infrequent voiding and a large bladder. A frequent voiding program partially relieved the pancreatitis, but final resolution necessitated conversion of the pancreaticoduodeno-cystostomy to a Roux-en-Y duodenojejunostomy at 6 months posttransplant. Both renal and pancreatic function are stable after 1 year, with no recurrence of pancreatitis since urinary undiversion. We believe pressure pancreatitis or urine reflux pancreatitis to be an infrequently reported cause of graft dysfunction in bladder-drained pancreas transplant recipients.     

Present status of pancreas transplantation in Japan--donation predominantly from marginal donors and modified surgical technique: report of Japan pancreas transplantation registry

In Japan, organ donation has been still limited because of the strict donor criteria. The aim of this study was to show the effectiveness of pancreas transplantation (PTx) by analyzing the outcomes even under poor donor conditions. Thirty-six cases of PTx (32 simultaneous pancreas and kidney transplantations [SPK], 4 pancreas after kidney transplantations) performed during the last 8 years were examined especially for donor characteristics. Mean donor age of 41.4 +/- 11.9 years was considerably older compared with that in the United States and Europe; donors aged over 40 years comprised 67% of the total. According to the criteria described by Kapur, 29 cases (81%) in our series would be considered marginal. Thus, to increase blood supply into the pancreatic head, the gastroduodenal artery (GDA) was anastomosed using donor artery to common hepatic artery or iliac Y graft. These procedures were performed in 16 of the 24 cases in which there was liver procurement. Eventually, 34 cases (94%) preserved GDA continuity. Mean total cold ischemic time of pancreatic grafts was 12 hours 15 minutes. Of 214 registrants, 17 patients on the waiting list for SPK died of diabetic complications. To date, patient survival remains 100% with a mean follow-up period of 33 months. Pancreas graft survivals at 1, 3, and 5 years posttransplantation were 92%, 80%, and 80%, respectively. In contrast, kidney survivals were 91%, 91%, and 91%, respectively. The integrity of the pancreas head and duodenum by preservation of the GDA continuity might have decreased the risk associated with the marginal donors.     

Multifocal osteonecrosis predominantly affecting the knees secondary to chronic alcohol ingestion: A case report and review

We present a case of multifocal osteonecrosis secondary to alcohol ingestion in a middle aged lady, after the exclusion of other causal factors. It presented initially with knee pain and subsequently necessitated arthroplasty; other areas became more problematic. This condition is rare and we present a literature review that reveals that after steroids the suspected link to alcohol is not so obvious. A high index of suspicion is required and treatment remains expectant and symptomatic. The role of screening is also discussed.     

胆肠胰结合部及其邻近区域外科手术的改进

目的: 总结几种胆肠胰部新型手术及其疗效 。方法及结果: 分析9例行胆肠胰部手术的特点及疗效。其中胰头部胰管及近邻手术3例;胆总管下端及壶腹部手术3例;十二指肠及近邻手术3例。根据各病例的病理及临床特点,设计并实施相应的新型手术方法,如胰头后侧径路主胰管切开取石术,胰头下部切除、钩突胰管空肠Roux-Y吻合术、经壶腹胆总管末端穿透伤直视下修补术、十二指肠节段切除术等,均获良好疗效 。结论: 本文介绍的新手术方法适合胆肠胰部的特殊病症,可有效预防胰、胆、十二指肠瘘等并发症。     

Unusual coexistence of caudal duplication and caudal regression syndromes

Caudal duplication syndrome includes anomalies of the genitourinary system, gastrointestinal tract, and the distal neural tube. Caudal regression syndrome presents with lumbosacral hypogenesis, anomalies of the lower gastrointestinal tract, genitourinary system, and limb anomalies. Both happen as a result of insult to the caudal cell mass. We present a child having features consistent with both entities.     

Eye-pursuit and reafferent head movement signals carried by pursuit neurons in the caudal part of the frontal eye fields during head-free pursuit

Eye and head movements are coordinated during head-free pursuit. To examine whether pursuit neurons in frontal eye fields (FEF) carry gaze-pursuit commands that drive both eye-pursuit and head-pursuit, monkeys whose heads were free to rotate about a vertical axis were trained to pursue a juice feeder with their head and a target with their eyes. Initially the feeder and target moved synchronously with the same visual angle. FEF neurons responding to this gaze-pursuit were tested for eye-pursuit of target motion while the feeder was stationary and for head-pursuit while the target was stationary. The majority of pursuit neurons exhibited modulation during head-pursuit, but their preferred directions during eye-pursuit and head-pursuit were different. Although peak modulation occurred during head movements, the onset of discharge usually was not aligned with the head movement onset. The minority of neurons whose discharge onset was so aligned discharged after the head movement onset. These results do not support the idea that the head-pursuit-related modulation reflects head-pursuit commands. Furthermore, modulation similar to that during head-pursuit was obtained by passive head rotation on stationary trunk. Our results suggest that FEF pursuit neurons issue gaze or eye movement commands during gaze-pursuit and that the head-pursuit-related modulation primarily reflects reafferent signals resulting from head movements.     

Treating the caudal septal deflection

Caudal septal deflection can be a challenging nasal deformity. Although there are a number of maneuvers available to manage this functional and aesthetic abnormality, each approach is effective in only a limited number of cases. For over 25 years, the senior author (N.J.P.) has employed a "modified swinging door" technique for treatment of the deviated caudal septum. Using this technique, the septal cartilage along the maxillary crest is dissected free but is not excised. Instead, the caudal septum is flipped over the nasal spine, which acts as a "doorstop" and secures the caudal septum in a straighter position. This maneuver may be useful in the armamentarium of the surgeon managing this potentially difficult technical challenge.     

Cystic dystrophy in heterotopic pancreas of the second part of the duodenum. One case of conservative surgical procedure

Duodenal cystic dystrophy due to ectopic pancreas deposit is an uncommon pathology. Diagnosis is made by modern imaging techniques, mainly endoscopic ultrasound which localizes precisely cysts in duodenal wall. The most frequent clinical symptoms are pain, duodenal obstruction, and weight loss. We report the case of a 40 year-old man with cystic dystrophy of the 2nd part of the duodenum, without chronic pancreatitis, treated by a conservative surgical procedure including segmental duodenal resection. This original approach is an alternative to the Whipple procedure.     

Growth of a nation part II: impact of recipient obesity on whole-organ pancreas transplantation

Obesity has reached epidemic proportions in the USA. Consequently, there is an increasing number of obese diabetic patients who would otherwise be appropriate candidates for pancreas transplantation (PTx). This is a retrospective study of all PTx performed at Indiana University between 2003 and 2009 (n = 308) comparing recipients with body mass index (BMI) < 25, 25-29.9, and ≥30 kg/m(2) Data included recipient and donor demographics, seven and 90-d graft loss, one-yr pancreas, kidney (for SPK only) and patient survival, causes of graft loss and death, peak amylase and lipase, length of stay, readmissions, complications, HbA1C, and c-peptide. Of the 308 PTx, 100 (32%) were overweight and 42 (14%) were obese. Obese recipients were older and more likely to be men. Donor demographics were similar. There was no difference in seven-d or 90-d graft loss, one-yr pancreas, kidney or patient survival, cause of graft loss or death, 30-d peak amylase or lipase, HbA1C, or C-peptide. The incidence of post-transplant technical, immunological and infectious complications was similar except for an increased incidence of cytomegalovirus infection in the obese group. Two recipients returned to insulin therapy despite normal C-peptide levels. Although technically challenging, PTx can be successful in select obese recipients with similar results compared to normal BMI recipients.