Endoscopic Ultrasound-Guided Tissue Acquisition Versus Fine Needle Aspiration for Diagnosis of Pancreatic Ductal Adenocarcinoma.

OBJECTIVES: Compare the 22G needle versus EchoTip ProCore® 20 (Cook Medical, Bloomington, IN, USA) on their handling, specimen suitability, amount of tissue obtained, diagnostic performance, the possibility of immunohistochemistry, and rate of adverse events. MATERIALS AND METHODS: This is a retrospective, comparative study of consecutively examined patients with pancreatic masses who underwent endosonography-guided fine needle aspiration (FNA) via the 22G needle, and endosonography-guided tissue acquisition (TA) via ProCore 20 (PC20). The operator evaluated needle insertion and subjectively classified the specimen. The pathologist measured the samples, classified the amount of tissue, and determined the influence of bleeding on the interpretation. RESULTS: A total of 129 patients participated in the study, out of whom 52 underwent endosonography-guided FNA with 22G and 77 underwent endosonography-guided TA with a PC20 needle. Malignant lesions were found in 106, and 23 had benign lesions. The duodenal route was used in 62% of patients. The 22G needle was easier to introduce (p=0.0495). However, PC20 obtained a larger amount (p<0.01) with fewer punctures (p<0.001). The PC20 also yielded a larger average microcore diameter (p=0.0032). Microhistology was adequate for 22G and PC20 in 22 (42.2%) and 50 (78.1%) specimens, respectively (p<0.001). Bleeding was not significantly different (p>0.999). Immunohistochemistry was possible in 36 (69.2%) and 40 (51.9%) specimens obtained by 22G and PC20, respectively (p=0.075). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 22G were 93.5%, 100%, 100%, 66.7%, and 94.2%, respectively; and for PC20, it was 95%, 100%, 100%, 85%, and 96.1%, respectively. Mild bleeding was the most common early adverse event, occurring in 2/52 (3.8%) 22G and 4/77 (5.2%) PC20 cases (p>0.05). CONCLUSIONS: The PC20 required fewer punctures and reduced the need for immunohistochemistry as it yielded better and larger microcores. Its ease of insertion into the target lesion makes it a good option to obtain satisfactory microcore specimens in difficult positions, such as the transduodenal route.

Disruption of proteome by an oncogenic fusion kinase alters metabolism in fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FLC) is a usually lethal primary liver cancer driven by a somatic dysregulation of protein kinase A. We show that the proteome of FLC tumors is distinct from that of adjacent nontransformed tissue. These changes can account for some of the cell biological and pathological alterations in FLC cells, including their drug sensitivity and glycolysis. Hyperammonemic encephalopathy is a recurrent problem in these patients, and established treatments based on the assumption of liver failure are unsuccessful. We show that many of the enzymes that produce ammonia are increased and those that consume ammonia are decreased. We also demonstrate that the metabolites of these enzymes change as expected. Thus, hyperammonemic encephalopathy in FLC may require alternative therapeutics.

Primary Pancreatic Lymphoma: Endosonography-Guided Tissue Acquisition Diagnosis.

Primary pancreatic lymphoma is a rare type of cancer, that accounts for 0.1-0.5% of lymphomas and about 0.2% of all primary pancreatic tumors. Diffuse Large B-cell Lymphoma is the most common subtype. The diagnosis is possible if the lymphoma is located in the pancreas, but the differential diagnosis with pancreatic ductal adenocarcinoma is difficult. The diagnostic accuracy of endosonography-guided fine needle aspiration is inadequate, and thus it is common to diagnose these masses only after surgical resection. The endosonography-guided tissue acquisition allows greater accuracy in the pancreatic masses, as it determines optimal access to histological analysis using tissue in paraffin blocks for complementary immunohistochemical, and molecular tests. Thus, this elaborate diagnostic environment allows the adoption of appropriate treatment strategies for patients with this condition. The authors describe four cases of primary pancreatic lymphoma indicated for surgical resection due to suspected pancreatic cancer, with the diagnosis of Diffuse Large B-cell Lymphoma obtained by endosonography-guided tissue acquisition, changing the therapeutic strategy through the adoption of adequate chemotherapy treatment with good progress.

First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis.

Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility. The operative time was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up. Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.

Molecular Basis of Hyperammonemic Encephalopathy in Fibrolamellar Hepatocellular Carcinoma.

Hyperammonemic encephalopathy is a potentially fatal condition associated with fibrolamellar hepatocellular carcinoma. The mechanism involved in hyperammonemia in patients with fibrolamellar carcinoma was unclear until a possible physiopathological pathway was recently proposed. An ornithine transcarboxylase dysfunction was suggested as a result of increased ornithine decarboxylase activity induced by c-Myc overexpression. This c-Myc overexpression resulted from Aurora kinase A overexpression derived from the activity of a chimeric kinase that is the final transcript of a deletion in chromosome 19, common to all fibrolamellar carcinomas. We performed the analysis of the expression of all enzymes involved and tested for the mutation in chromosome 19 in fresh frozen samples of fibrolamellar hepatocellular carcinoma, non-tumor liver, and hepatic adenomatosis. The specific DNAJB-PRKACA fusion protein that results from the recurrent mutation on chromosome 19 common to all fibrolamellar carcinoma was detected only in the fibrolamellar carcinoma sample. Fibrolamellar carcinoma and adenomyomatosis samples presented increased expression of Aurora kinase A, c-MYC, and ornithine decarboxylase when compared to normal liver, while ornithine transcarbamylase was decreased. The proposed physiopathological pathway is correct and that overexpression of c-Myc may also be responsible for hyperammonemia in patients with other types of rapidly growing hepatomas. This gives further evidence to apply new and adequate treatment to this severe complication.

Retroperitoneal Bronchogenic Cyst Mimicking a Pancreatic Cystic Lesion with Extremely High Level of Intralesional Fluid CA-19.9 Antigen: Benign in Disguise.

Bronchogenic cysts are congenital benign tumors resulting from abnormal budding of the primitive foregut. Usually presented on the posterior mediastinum, its presence on the retroperitoneum is extremely rare. We present an asymptomatic lady patient with a retroperitoneal cystic lesion that was submitted to endoscopic ultrasound-guided biopsies and intracystic fluid aspiration with histology excluding malignance despite intracystic fluid biochemical analysis that disclosed extremely high carbohydrate antigen 19-9. Definite diagnosis of bronchogenic cyst was only possible after complete surgical resection of the lesion. Furthermore, we discuss the use of this antigen as a tumor marker in this situation and its relevance to the preoperative diagnosis of such lesions.

Totally robotic caudate lobe liver resection: Bridge over troubled water.

BACKGROUND: Minimally invasive hepatectomy has well-known advantages over the traditional open approach. Inherent limitations of laparoscopy make major hepatectomies and the resection of upper and posterior segments a great technical challenge. The robotic approach overcomes most of these limitations, and this technology is most useful in the resection of the deeply located caudate lobe. METHODS: We describe the robotic caudate lobe resection technical aspects, using the first robotic resection of the caudate lobe to treat a biphenotypic hepatocholangiocarcinoma to illustrate the procedure. We also performed a literature review on the current status of the robotic approach to segment (Sg) 1. RESULTS: Technical approach to the robotic caudate lobe resection is described in a patient with uneventful post-operative recovery. Literature review demonstrated only four previous authors reporting the use of this technique. CONCLUSION: We present a step-by-step approach to the hepatic Sg 1 resection by robotic approach.

Long-term survival after surgical treatment followed by adjuvant systemic therapy for primary duodenal melanoma.

Primary mucosal malignant melanomas of the gastrointestinal tract are rare tumors associated to poor prognosis. Primary duodenal involvement by pigmented lesions is even more uncommon, and only a few reports exist in the literature. We report the case of a patient with large primary duodenal melanoma that presented with upper intestinal obstruction and bleeding that was submitted to urgent pancreaticoduodenectomy followed by adjuvant systemic therapy with an oral alkylating agent (temozolomide) plus intravenous cisplatin. The patient presents no signs of recurrence 3 years after the surgery. We consider that radical surgical resection followed by systemic therapy is a safe and effective treatment strategy option for primary mucosal gastrointestinal melanomas.

Laparoscopic glissonean approach: Making complex something easy or making suitable the unsuitable?

BACKGROUND: The use of laparoscopic glissonean approach has many potential benefits such as shorter operative times, lower blood loss with low morbidity. METHODS: The aim with this study was to perform an evaluation of 12 years of our experience with laparoscopic glissonean approach in liver surgery, from a technical standpoint using a prospective database. Anatomical laparoscopic liver resections using hilar dissection and non-anatomical resections were excluded from this study. RESULTS: 327 patients (170 females and 157 males) with mean age of 56 years were included. 196 (60%) of procedures were major resections. 65% of procedures were performed in the last 5 years. 208 patients were operated on for secondary lesions. In 38 patients the liver was cirrhotic. Morbidity was 37.3% and 90-day mortality occurred in 2 patients (0.6%). Blood transfusion was necessary in 10.7% of patients. Median hospital stay was 4 days. CONCLUSIONS: Laparoscopic glissonean approach is a safe and feasible technique. It may be preferred in some clinical situations as it is associated with shorter operative times, lower blood loss, and low morbidity. It is superior to standard laparoscopic hepatectomy when an anatomical resection, especially if a segment or section is to be removed. However, application of this technique requires accurate preoperative tumor localization, identification of potential anatomic pedicle variations, as well as surgeon expertise.

Robotic ALPPS.

BACKGROUND: The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure is a useful strategy to treat patients with advanced liver tumors and small future liver remnants. This video presents a robotic ALPPS procedure to treat synchronous colorectal liver metastases. METHODS: A 71-year-old man with liver metastases from sigmoid cancer was referred. A multidisciplinary team decided on chemotherapy followed by liver resection (first), then colon resection. After four cycles, objective response was observed and the multidisciplinary team then chose the ALPPS procedure. The future liver remnant (segments 3 and 4 and the Spiegel lobe) was 24%. A robotic approach was proposed. Colon resection was performed after the ALPPS procedure, also using the robotic approach. RESULTS: The duration of the first stage was 293 min, and the technique used in the first stage was partial ALPPS (parenchymal transection deep to 2 cm above the inferior vena cava) with preservation of the right hepatic duct. The patient was discharged on the fourth day. The second stage of the procedure took 245 min. Recovery was uneventful and the patient was discharged on the fourth day. Finally, the patient underwent robotic resection of the primary colorectal neoplasm. The surgery lasted 182 min, recovery was uneventful, and the patient was discharged on the fifth postoperative day. Final pathology disclosed a T3N1bM1 adenocarcinoma. Liver pathology confirmed colorectal metastases with partial response. All surgical margins were free. Currently, the patient is well, with no signs of disease 5 months post-procedure. CONCLUSIONS: Robotic ALPPS is feasible and safe. The robotic approach may have some advantages over the laparoscopic and open ALPPS approaches. This video may help oncological surgeons to perform this complex procedure.