Ошибки в диагностике новообразований поджелудочной железы: интрапанкреатическая долька селезенки

Introduction. Accessory spleen (splenunculus) is one of the most common benign congenital anomalies in humans. The location of splenunculus may vary from perisplenic, greater omental or mesenterial to intraparenchymal (pancreas, stomach, duodenum, etc.). In the latter case, the additional spleen is called ectopic (from the greekektoposdisplaced). Most frequently detection of such splenic lobules occurs accidentally via abdominal ultrasound.Objective: two cases of verified intrapancreatic accessory spleen (IPAS) and main criteria for differential diagnosis with other hypervascular pancreatic lesions.Materials and methods. We present two case reports: a 43-year-old woman with a history of kidney cancer and a healthy 61-year-old man. In both cases, pancreatic neuroendocrine neoplasia (NEN) was initially suspected. Preoperative diagnostics included abdominal ultrasound examination and multiphase dynamic computed tomography (CT) with intravenous bolus nonionic iodine-based contrast agent (native, arterial – 10 sec, venous – 60 sec and delayed – 300 sec after threshold density of 150 HU in the aorta was exceeded). In one case magnetic resonance imaging (MRI) including axial, sagittal and coronal T1and T2-weighted images, diffusion-weighted images and dynamiccontrast-enhanced series with gadolinium chelate was performed. Both patients underwent robotic assisted distal pancreas resection. Morphological examination revealed IPAS.Results. In contrast-enhanced computed tomography IPAS has densitometric parameters similar to the spleen. Generally, magnetic resonance imaging does not differentiate IPAS, NEN and hypervascular metastases, since all three are generally T2-hyperintense and T1-hypointense. Contrast enhancement pattern with gadolinium chelateswas similar to CT-contrast enhancement pattern.Conclusion. Intrapancreatic accessory spleen does not require surgical treatment. Therefore, differential diagnosis between IPAS and neuroendocrine neoplasia, solid pseudopapillary tumor and hypervascular pancreatic metastases is crucial. MRI has an advantage with non-invasive diffusionweighted images (DWI). The apparent diffusion coefficient (ADC) of IPAS will be quantitatively similar to the main spleen while other lesion will demonstrate lower ADC values. Scintigraphy with red blood cells bound with 99mTc utilizes the reticuloendothelial system (RES) in the spleen demonstrating characteristic uptake in the IPASand the main spleen. Ultrasound with color Doppler and contrast enhancement may be a good addition to our armamentarium. One can evaluate the vascular pedicle of the IPAS, as well as contrast agent retention in RES via sonography. We believe the multimodal approach including MRI with DWI/ADC to be the most effective.Введение. Добавочная селезенка является одним из распространенных доброкачественных врожденных пороков развития человека. Ее расположение может быть разнообразным, как вблизи селезенки, большого сальника и брыжейки тонкой кишки, так и в структуре других органов, например в поджелудочной железе, стенке желудка или двенадцатиперстной кишки. В последнем случае добавочную селезенку называют эктопированной (от греч. ektopos – смещенный). Выявление подобных селезеночных долек происходит, как правило, случайно при ультразвуковом исследовании (УЗИ) органов брюшной полости.Цель исследования: представить клинические наблюдения верифицированной интрапанкреатической добавочной селезенки (ИПДС), выявить основные критерии дифференциальной диагностики данного патологического состояния с другими гиперваскулярными образованиями поджелудочной железы.Материал и методы. Представлены два клинических наблюдения: женщина 43 лет, имеющая в анамнезе оперированный рак почки, и мужчина 61 года, у которого не было жалоб и сопутствующей патологии на момент обследования. В обоих случаях по результатам инструментального обследования была заподозрена нейроэндокринная неоплазия (НЭН) хвоста поджелудочной железы. Инструментальное обследование данных пациентов включало УЗИ органов брюшной полости с применением цветового дуплексного картирования; мультиспиральную компьютерную томографию (МСКТ) органов брюшной полости с внутривенным болюсным контрастированием неионным йодистым контрастным препаратом и сканированием в нативную, артериальную (10 с от достижения пороговой плотности 150 ед.H в просвете нисходящей аорты), в венозную (60 с от начала введения контрастного препарата) и в отсроченную фазы контрастного усиления (на 5–6-й минуте от начала введения контрастного препарата). В одном случае проведены магнитно-резонансная томография (МРТ) в режимах Т1и Т2ВИ в аксиальной, сагиттальной и корональной плоскостях, динамическое внутривенное контрастирование и диффузионно-взвешенная МРТ (ДВ-МРТ). Обоим пациентам выполнено оперативное вмешательство в объеме робот-ассистированной дистальной резекции поджелудочной железы. При морфологическом исследовании была выявлена ИПДС.Результаты. Эктопированная ткань селезенки имела денситометрические показатели, аналогичные таковым в основном органе, и сходный характер контрастирования. МРТ не позволила дифференцировать ИПДС, НЭН и гиперваскулярные метастазы.Заключение. ИПДС не требует хирургического лечения. Именно поэтому необходима дифференциальная диагностика с НЭН, солидной псевдопапиллярной опухолью и гиперваскулярными метастазами поджелудочной железы. При этом максимально результативным является комплексный подход с использованием нескольких методов лучевой диагностики, включающий МРТ (с ДВ-МРТ) и сцинтиграфию с 99mTc. Наличие в структуре селезенки ретикулоэндотелиальной системы (РЭС) позволяет применять в диагностике ее эктопированных долек сцинтиграфию с эритроцитами в комплексе с 99mTc, при которой отмечается характерное накопление радиофармпрепарата в ИПДС и основной селезенке. УЗИ с цветовым допплеровским картированием и контрастным усилением может стать хорошим дополнением в дифференциально-диагностическом поиске. Метод позволяет оценить сосудистую ножку ИПДС и характер накопления контрастного препарата в РЭС. У МРТ есть преимущество за счет применения диффузионно-взвешенных изображений. Исчисляемый коэффициент диффузии (ИКД) ткани селезенки будет соответствовать основной селезенке, в то время как другие новообразования имеют более низкие значения ИКД

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Insulin-producing tumor of pancreas in a young patient: the search for germline mutations. Clinical case

Insulinoma is the most common functioning tumor of the pancreas. Approximately 5% of cases of the disease is associated with the syndrome of multiple endocrine neoplasia type 1 (MEN-1), caused by mutation in the gene MEN1. The MEN-1 is manifested by pituitary adenomas and adenomas of parathyroid glands, pancreatic neuroendocrine tumors, tumors of thyroid gland, adrenal glands, intestine, carcinoids of lungs and other organs. Patients with MEN-1 often have angiofibromas, collagenomas and lipomas. However, in 5–10% of patients with clinical manifestations of this syndrome, mutations in MEN1 cannot be detected. In such cases, the disease can be caused by various disorders (mutations, polymorphisms, etc.) in other genes. More than 10 genes, associated with insulin-producing pancreatic tumor, are described in the literature. In the presented clinical case, an extended genetic study was performed in a young patient with insulinoma and a suspicious phenotype of MEN-1. The article emphasizes the need to search for new genetic markers that predispose to the development of insulinoma, and the subsequent introduction of panel of genes sequencing in such patients. Genetic testing is indicated primarily for young patients with multifocal lesions, family history and associated pathology

Heterogeneity of management practices surrounding operable gallbladder cancer – results of the OMEGA-S international HPB surgical survey

Background: Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies. Methods: A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies. Results: Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites. Conclusion: Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135–15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359–5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138–5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184–5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598–9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090–6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286–5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912–7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138–0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143–0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990). Graphical abstract: [Figure not available: see fulltext.]

coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis): The MANCTRA-1 international audit

Background/objectives: Reports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines. Methods: All consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data. Results: Complete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P&nbsp;=&nbsp;0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P&nbsp;&lt;&nbsp;0.00001), early enteral feeding (33.2%, χ2 11.51, P&nbsp;=&nbsp;0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P&nbsp;&lt;&nbsp;0.00001), with wide variability based on the admitting speciality. Conclusions: The results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality. Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990)

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

IMPORTANCE Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.OBJECTIVE To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.DESIGN, SETTINGS, AND PARTICIPANTS This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.MAIN OUTCOMES Mortality and morbidity after EC.RESULTS Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P &lt;.001) and morbidity (7.7% vs 3.7%, P &lt; .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P &lt; .001), morbidity (30 [30.3%] vs 57 [5.5%], P &lt; .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P &lt; .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P &lt; .001), morbidity (30 [30.3%] vs 17 [10.3%], P &lt; .001), and infections (12 [14.6%] vs 2 [1.3%], P &lt; .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).CONCLUSIONS AND RELEVANCE This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)