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ABSTRACT Context Synchronous cystic neoplasms of pancreas are a highly rare occurrence. Case report We report a very rare case of coexistent serous cystadenoma and multi-side branch intraductal papillary mucinous neoplasm (IPMN). Conclusion To our knowledge, there has been only one previous case report in the literature of a synchronous serous cystadenoma and a solitary IPMN lesion. This case report is intended to increase the awareness of this condition while alluding to the need for diligent examination by endosonographers. It also highlights the clinical impact of endosonography on the diagnosis and management of cystic legions in the pancreas

Training Paradigms in Hepato-Pancreatico-Biliary Surgery: an Overview of the Different Fellowship Pathways

Hepato-pancreatico-biliary (HPB) surgery, and the training of HPB surgeons, has evolved significantly over the last several decades. The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO) ACGME fellowship, the American Society of Transplant Surgeons (ASTS) fellowship, and the Americas Hepatopancreaticobiliary Association (AHPBA) fellowship. These fellowships offer variable experiences in pancreas, liver, and biliary cases, and each pathway offers a unique perspective on HPB surgery. The CGSO ACGME, ASTS, and AHPBA fellowships represent decades of work by the three major surgical leadership stakeholders to improve and ensure quality training of future HPB surgeons. The best care is provided by the HPB surgeon who has been trained to understand the importance of all available treatment options within the context of a multidisciplinary setting. The three fellowship pathways are outlined in this paper with the nuances and variations characteristic of the different training programs highlighted

Role of yttrium-90 selective internal radiation therapy in the treatment of liver-dominant metastatic colorectal cancer: An evidence-based expert consensus algorithm

Surgical resection of colorectal liver metastases is associated with greater survival compared with non-surgical treatment, and a meaningful possibility of cure. However, the majority of patients are not eligible for resection and may require other non-surgical interventions, such as liver-directed therapies, to be converted to surgical eligibility. Given the number of available therapies, a general framework is needed that outlines the specific roles of chemotherapy, surgery, and locoregional treatments [including selective internal radiation therapy (SIRT) with Y-90 microspheres]. Using a data-driven, modified Delphi process, an expert panel of surgical oncologists, transplant surgeons, and hepatopancreatobiliary (HPB) surgeons convened to create a comprehensive, evidence-based treatment algorithm that includes appropriate treatment options for patients stratified by their eligibility for surgical treatment. The group coined a novel, more inclusive phrase for targeted locoregional tumor treatment (a blanket term for resection, ablation, and other emerging locoregional treatments)

The importance of assessing the SMA margin in patients undergoing pancreaticoduodenectomy

Aim: The purpose of this study is to examine the true incidence of superior mesenteric artery (SMA) positivity in patients who have superior mesenteric vein (SMV) positivity while undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Methods: All patients who underwent PD for PDAC between January 2005 and December 2011 were retrospectively identified from our database. Patients deemed resectable by NCCN guidelines, protocol CT scans, and endoscopic ultrasound were included. The PD specimen was inked using five colors to specifically identify and study the SMV and SMA margins. We also analyzed and compared R1-sub groups (R1A group- SMA and SMV positive; R1B group - SMV positive, SMA negative). Results: 98 patients underwent PD for resectable pancreatic adenocarcinoma. 75 patients (76.5%) were found to have negative surgical margin on final pathology (R0 group) while 23 patients (23.4%) had positive SMV margins (R1 group). In the R1 group, 11 patients (47.8%) were found to have positive SMA margin (R1A group) and 12 patients were SMV positive and SMA negative (R1B group). No statistically significant survival difference was noted between R0 and R1 or between R1-A and R1-B. Conclusion: This study demonstrates that with careful inking of the SMA and SMV margins, there is a high rate of concurrent SMA positivity in those patients that are SMV positive. There was no impact on survival. Accurate margin assessment is critical by careful examination and inking of the SMA and SMV margin. </jats:p

Hemoglobin A1c can be helpful in predicting progression to diabetes after Whipple procedure

AbstractIntroduction: Normoglycemic patients undergoing pancreaticoduodenectomy (Whipple procedure) often inquire whether they will be diabetic postoperatively. There is limited information on this issue. We therefore looked at a more subtle measurement of long-term glycemic control, hemoglobin A1c (HgbA1c), as a prognostic tool in predicting progression to diabetes post Whipple. Patients and methods: A retrospective review over a 6-year period of all patients undergoing Whipple procedures at a single institution was conducted. In all, 27 patients had no prior history of diabetes, complete follow-up, and measured preoperative HgbA1c values. Postoperative diabetes was defined as the need for oral hypoglycemic agents or insulin. These charts were analyzed for progression to diabetes after Whipple. Results: Of the 27 patients, 10 were considered to have postoperative diabetes. The average preoperative HgbA1c value for these patients was 6.3±0.66. This was statistically different from the 17 patients without postoperative diabetes (average HgbA1c 5.2±0.39, p<0.001). The positive predictive value, negative predictive value, sensitivity, and specificity were 82%, 94%, 90%, and 88%, respectively. Conclusion: This study demonstrates that progression to diabetes is very unlikely after Whipple operation if the preoperative HgbA1c value is in the normal range. The apparent utility of HgbA1c in predicting postoperative diabetes in this small study suggests that this laboratory test may be very helpful in counseling patients for Whipple operation