Specificities of acute cholangitis in patients with cancer: a retrospective comparative study of 130 episodes.

Pancreatic and biliary duct cancers are increasing causes of acute cholangitis (AC). We retrospectively characterize 81 cancer-associated cholangitis (CAC) compared to 49 non-cancer-associated cholangitis (NCAC). Clinical and biological presentations were similar. However, in CAC, antibiotic resistance and inadequate empirical antibiotic therapy were more frequent; more patients required ≥ 2 biliary drainages; and mortality at day 28 was higher than in NCAC. Death was associated with initial severity and CAC in a multivariate analysis. Cholangitis associated with pancreatic or biliary duct cancers requires specific empirical antimicrobial therapy; early use of biliary drainage may improve outcomes.

Endoscopic management of pancreatic fistula after enucleation of pancreatic tumors.

INTRODUCTION: Pancreatic fistula (PF) are frequent after pancreatic surgical resection, and particularly after enucleation. Endoscopic treatment might be proposed for postoperative PF, but has never been evaluated after pancreatic enucleation. PATIENTS AND METHODS: From January 2000 to June 2012, 161 patients underwent pancreatic enucleation in our center. In case of PF in the postoperative period, conservative management (somatostatin analogs combined with enteral or parenteral nutrition and drainage) was proposed. If PF persisted after 20 days (output >50 cc/d), endoscopic treatment (pancreatic sphincterotomy and stent placement if evidence of main duct leakage) was proposed. Primary outcome was the delay of PF closure after endoscopic treatment. RESULTS: Ninety-one patients (56 %) developed postoperative PF. PF closed within 3 weeks with conservative management in 78 (86 %) patients. Endoscopic treatment was required in 7 (8 %) patients. Daily PF output was 240 (50-300) mL. Pancreatic sphincterotomy was performed in all patients. A pancreatic stent was inserted in 4 of 5 patients with main pancreatic duct leakage. One patient presented a stent migration requiring a second procedure. No complication of endoscopic treatment was reported. The closure of PF was obtained in all cases, after 13 (3-24) days. Pancreatic stents were removed after 2, 5, 5, and 8 months, respectively. Median postoperative follow-up was 46 (21-70) months. At study endpoint, two patients had small asymptomatic pancreatic collections, four had mild dilatation of main pancreatic duct upstream pancreatic duct leakage, and none developed exocrine pancreatic insufficiency, diabetes, or recurrence of pancreatic tumor. CONCLUSIONS: PF occurs in half patients after enucleation. Endoscopic treatment combining pancreatic sphincterotomy and stenting is safe and effective if conservative treatment fails, avoiding a complementary pancreatic resection.

Endoscopic papillectomy for early ampullary tumors: long-term results from a large multicenter prospective study.

BACKGROUND AND STUDY AIMS: Endoscopic papillectomy of early tumors of the ampulla of Vater is an alternative to surgery. This large prospective multicenter study was aimed at evaluating the long-term results of endoscopic papillectomy. PATIENTS AND METHODS: Between September 2003 and January 2006, 10 centers included all patients referred for endoscopic papillectomy and meeting the inclusion criteria: biopsies showing at least adenoma, a uT1N0 lesion without intraductal involvement at endoscopic ultrasound (EUS), and no previous treatment. A standardized endoscopic papillectomy was done, with endoscopic monitoring with biopsies 4 - 8 weeks later where complications were recorded and complementary resection performed when necessary. Follow-up with duodenoscopy, biopsies, and EUS was done at 6, 12, 18, 24 and 36 months. Therapeutic success was defined as complete resection (no residual tumor found at early monitoring) without duodenal submucosal invasion in the resection specimen in the case of adenocarcinoma and without relapse during follow-up. RESULTS: 93 patients were enrolled. Mortality was 0.9 % and morbidity 35 %, including pancreatitis in 20 %, bleeding 10 %, biliary complications 7 %, perforation 3.6 %, and papillary stenosis in 1.8 %. Adenoma was not confirmed in the resection specimen in 14 patients who were therefore excluded. Initial treatment was insufficient in 9 cases (8 carcinoma with submucosal invasion; 1 persistence of adenoma). During follow-up, 5 patients had tumor recurrence and 7 died from unrelated diseases without recurrence. Finally, 81.0 % of patients were cured (95 % confidence interval 72.3 % - 89.7 %). CONCLUSION: Endoscopic papillectomy of selected ampullary tumors is curative in 81.0 % of cases. It must be considered to be the first-line treatment for early tumors of the ampulla of Vater without intraductal invasion.

Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging.

OBJECTIVES: Diagnosis of internal pancreatic fistulae (IPF) resulting in ascites or pleural effusions may be facilitated by multislice helical CT-scan and MR-pancreatography [MRP]). Conservative treatment with parenteral nutrition and somatostatin analogues (+/- pancreatic stenting) yields varying results. We aimed to evaluate the usefulness of helical CT and MRP in the diagnosis of IPF. The outcome of patients when the following stepwise treatment algorithm is applied is also descried: i) conservative (enteral nutrition and somatostatin analogues); ii) endoscopic stenting; iii) surgery. METHODS: Sixteen consecutive patients (13 M; median age 42 (14-54) yrs) with chronic pancreatitis (alcoholic 15, hereditary 1) and an IPF were prospectively included between March-01 to December-03. All serous effusions (ascites, N=10; pleural effusion, N=6) contained high lipase [median: 7800 (506-59000) U/mL]. Patients with fistulae communicating with pancreatic pseudocysts were not included. RESULTS: The diagnosis of IPF and its site were determined in 12/16 patients by CT and 14/15 patients by MRP (site of rupture: head: N=5; isthmus: N=5; body-tail: N=6) and confirmed by ERCP or surgery in 9. Localized atrophy of pancreatic parenchyma adjacent to pancreatic duct rupture was observed in 12 patients (75%). The median follow-up was 30 months (18-51). Early surgery was required in 3 patients (2 with infection of serous fluid at initial aspiration analysis). Thirteen entered the treatment algorithm: - seven patients responded favorably (54%) to conservative treatment (enteral nutrition and somatostatin analogues); - pancreatic stenting, possible in 4 of 6 patients, was successful in closing the IPF in 2; - surgery was required in the 4 remaining patients. Preoperative localization of the rupture site was possible in all patients using non-invasive imaging thus guiding elective intervention in all patients requiring surgery. CONCLUSION: Helical CT scan and MRP are useful in localizing MPD rupture sites and fistulae and may obviate the need for pancreatic opacification. A systematic treatment algorithm can be safely used starting with medical strategies (enteral nutrition safely replacing the parenteral route) progressing to endoscopy and finally surgery. Overall about 44% of patients require surgery initially or at follow-up.

Surgical Ampullectomy with Complete Resection of the Common Bile Duct: a New Procedure for Radical Resection of Non-invasive Ampulloma with Biliary Extension.

Extension of ampulloma into the lower common bile duct (CBD) is observed in up to 30% of cases. This biliary extension can prevent complete tumor resection thus is considered as a contraindication for endoscopic and even surgical ampullectomy. For ampullomas associated with a prolonged biliary extension, a pancreaticoduodenectomy is associated with a high morbidity and can be considered as an overtreatment for a benign neoplasm. The present study describes a new surgical approach including ampullectomy with complete resection of the intrapancreatic CBD and restoration of both biliary and pancreatic flow by two separate anastomoses. This procedure was performed in seven patients for a non-invasive ampulloma with a 25- to 70-mm CBD involvement. No patients died and three developed postoperative complications. Resection was R0 in all patients but one. With a 24-month median follow-up (range = 3-84), no patients developed pancreatic insufficiency or tumor recurrence.

Reconstruction of Bile Duct Injury and Defect with the Round Ligament.

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction.

Epidemiology of pancreatic cancer in France: descriptive study from the French national hospital database.

INTRODUCTION: Although indirect evidence suggests that the incidence of pancreatic adenocarcinoma has increased in the last decade, few data are available in European countries. The aim of the present study was to update the epidemiology of pancreatic cancer in France in 2014 from the French national hospital database (Programme de Médicalisation des Systèmes d'Information). PATIENTS AND METHODS: All patients hospitalized for pancreatic cancer in France in 2014 in public or private institutions were included. Patient and stays (length, type of support, institutions) characteristics were studied. The results were compared with those observed in 2010. RESULTS: A total of 13 346 (52% men, median age 71 years) new patients were treated for pancreatic cancer in 2014, accounting for a 12.5% increase compared with 2010. Overall, 22% of patients were operated on. Liver metastases were present in 60% of cases. The disease accounted for 146 680 hospital stays (+24.8% compared with 2010), 76% of which were related to chemotherapy (+32%). The average annual number and length of stay were 7 and 2.6 days, respectively. In 2014, 11 052 deaths were reported (+15.8%). CONCLUSION: Approximately 13 350 new cases of pancreatic cancer were observed in France in 2014. The increase in incidence was associated with a marked increase in hospital stays for chemotherapy.

Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor.

BACKGROUND: The influence of preoperative biliary drainage on the postoperative course of patients undergoing pancreaticoduodenectomy (PD) remains controversial. Among drawbacks of biliary drainage, bile contamination and its consequences are incompletely evaluated. This study aimed to compare outcomes after PD in patients with sterile and those with infected bile. STUDY DESIGN: Seventy-nine consecutive patients underwent PD for periampullary tumor with routine bile culture and antibiotic prophylaxis with cefazolin. The postoperative course of 35 patients with infected bile (group B+) was compared with that of 44 patients with sterile bile (group B-). RESULTS: The distribution of tumors was comparable except for ampullary carcinoma, which was more frequent in group B+ patients (p = 0.001). Interventional biliary endoscopy was performed preoperatively in 80% of patients in group B+ versus 14% in group B- (p < 0.001), including 9 isolated sphincterotomies (20% versus 5%, p < 0.03) and 20 endoprosthesis insertions (57% versus 0%, p < 0.0001). More patients in group B+ were classified as American Society of Anesthesiologists (ASA) 2 (p = 0.04). Operative time and blood loss were similar in both groups. One patient died postoperatively (group B+). Overall morbidity was increased in group B+ (77% versus 59%, p = 0.05). Postoperative infectious complications, all demonstrated bacteriologically, were more frequent in group B+: (65% versus 37%, p = 0.003). In group B+, bile was polybacterial in 54% of patients and isolated microorganisms were resistant to cefazolin in 97%. In patients with infectious complications, the same germ was isolated in bile and another sample in 49%. CONCLUSIONS: In patients undergoing PD, bile infection is related to previous interventional biliary endoscopy in 80% of patients and is associated with an increased rate of postoperative infections. During PD for ampullary carcinoma or after interventional biliary endoscopy, a specific antibioprophylaxis should be evaluated.

[Osteoclastic giant cell tumour of the pancreas]. / Tumeur à cellules géantes ostéoclastiques du pancréas.

Osteoclast giant cell tumours are bone tumours that occur in adults, and that are considered benign by WHO but locally aggressive. Strictly identical tumours are described in the pancreas, without simultaneous bone localization. We report the case of a 62-year woman with an osteoclast giant cell tumour of the distal pancreas, without any epithelial component, which was diagnosed after pancreatic resection and with no signs of recurrence after a 24-month follow-up. These pancreatic tumours are rare, with a very poor prognosis, an unclear histogenesis; they are often confused with pleomorphic or undifferentiated pancreatic carcinomas including a component of osteoclast giant cell. These osteoclast giant cell tumours of the pancreas usually present as large cystic tumours. In certain cases, complete resection can result in long-term survival.