The caudal boundaries of the mesopancreatoduodenum based on the vascular anatomy associated with pancreaticoduodenectomy

Background The mesopancreas is important during pancreaticoduodenectomy (PD) in patients with periampullary and pancreatic head carcinoma. This study aimed to investigate whether the duodenojejunal uncinate process vein (DJUV) is a useful anatomical landmark for the caudal border of mesopancreatoduodenum resection.MethodsThis study enrolled 100 adult patients with hepatobiliary pancreatic disease who underwent preoperative multidetector-computed tomography (CT). The anatomy of the key blood vessels involved during PD was analyzed by preoperative CT. The DJUV was defined as the vein draining from the upper jejunum to the superior mesenteric vein adjacent to the uncinate process.ResultsAmong 89 cases, the first jejunal vein was the DJUV, whereas the second jejunal vein was the DJUV in 11 cases. The inferior pancreaticoduodenal artery and vein were located on the cranial side of the DJUV in all cases. The distance between the middle colonic artery and the DJUV was within 10 mm in 81% of cases, suggesting that resection of the mesopancreatoduodenum cranial to the DJUV provided sufficient dissection of regional lymph nodes around the superior mesenteric artery.ConclusionThe DJUV may be a useful anatomical landmark for the caudal border of the mesopancreatoduodenum resection during PD.

A case report of mucinous adenocarcinoma derived from intra-ampullary papillary-tubular neoplasm with a malignant course

Background Intra-ampullary papillary-tubular neoplasm (IAPN) has been classified as a Vater papillary tumor. The prognosis of IAPN is generally relatively good. Here, we describe a patient with a mucinous adenocarcinoma cluster in the Vater papilla of IAPN origin. Clinical presentation The patient was a 66-year-old man who was admitted to our hospital after a diagnosis of pancreatic head carcinoma based on a pancreatic duct dilatation found on abdominal ultrasound. CT showed a 40 mm lesion in the pancreatic head and expansion of the main pancreatic duct to a maximum diameter of 9 mm on the caudal side of the lesion. The extrahepatic bile duct had also expanded to a maximum diameter of 8 mm. PET/CT showed fluorodeoxyglucose (FDG) accumulation of SUVmax 6.02 that corresponded to the tumor in the pancreatic head, though it did not suggest distant metastasis. The patient was diagnosed with pancreatic head carcinoma T3 N0 M0 Stage IIA and underwent a pancreaticoduodenectomy. Pathology indicated that the tumor in the pancreatic head was a benign inflammatory lesion. On the other hand, the papillotubular tumor pervading the lumen in the duodenal papillary common channel met the criteria for IAPN, and a mucinous adenocarcinoma cluster found in the surrounding stroma suggested malignant transformation of IAPN. No metastasis to lymph nodes was demonstrated. With regard to the mucus phenotype of each lesion, the IAPN was MUC2 and MUC5AC positive, while the mucinous adenocarcinoma was MUC2-positive and MUC5AC-negative. In addition, CD10 was negative in both lesions, suggesting that mucus transformation from the gastric type to the intestinal type was a key element. A blood test 10 months after surgery showed increased CA19-9 (105 U/mL) and CEA (7.1 ng/mL). Abdominal CT showed multiple cystoid nodes in the liver, which were diagnosed as multiple liver metastases of mucinous adenocarcinoma transformed from the IAPN. Conclusions We reported a case with IAPN that developed in the Vater papilla, which took an extremely malignant course. IAPN generally has a good prognosis, but it is important to understand that a malignant course may occur.

Abdominal Tuberculosis With Pancreatic Head Involvement Mimicking Pancreatic Malignancy in a Young Man: A Case Report

Background：Pancreatic tuberculosis is a rare disease, even in immuocompentent hosts. Abdominal tuberculosis involving the pancreatic head and peripancreatic areas may simulate pancreatic head carcinoma.Case presentation: We herein present the case of a 32-year-old man who was admitted to our hospital for intermittent epigastric pain and weight loss. Computed tomography scan and magnetic resonance imaging revealed a mass in the head of the pancreas.The lesion was initially diagnosed as pancreatic head carcinoma on abdominal imaging. Laparotomy confirmed the diagnosis of pancreatic tuberculosis, while he test for acid-fast bacilli was negative before operation and the patient fully recovered after six month of standard anti-tuberculosis treatment.Conclusions: The present case is reported to emphasize the importance of including pancreatic tuberculosis in the differential diagnosis of pancreatic lesions, under the premise of safety, we recommend endoscopic ultrasound-guided fine needle aspiration biopsy for diagnosis.