- Email: [email protected]
Pancreatic heterotopia in the skin of the abdominal wall
Journal of Pediatric Surgery (2009) 44, 2057–2060
www.elsevier.com/locate/jpedsurg
Correspondence
Pancreatic heterotopia in the skin of the abdominal wall To the Editor, Heterotopic pancreas is recognized throughout the gastrointestinal tract in various sites [1]. The location of the lesion in the skin of the abdominal wall is a rare occurrence; and this report in a one and half-year old child is probably the second such case to the best of our knowledge [2]. This may be found in all age groups, although the condition is only rarely encountered in children. A one-and-half-year-old child presented with a small cystic mass of 2 months duration, measuring 2.0 cm in diameter located superficially in the abdominal wall below the umbilicus. It was clinically diagnosed as urachal cyst. The lesion was excised, and the operative note described a cyst containing straw-colored fluid without any internal connections. The gross specimen comprised a thin elongated grayish white tissue with a firm nodular swelling at one end measuring 0.3 cm in diameter. On cut section, the nodule was solid and yellowish in appearance. Histopathologic study was done with H&E staining. Microscopic examination revealed a circumscribed lesion composed of solid nests of acini and ducts resembling normal pancreatic tissue (Fig. 1). Pancreatic islet cells were also identified as clusters of small
Fig. 1 Pictomicrograph showing solid nests of pancreatic acini and ducts (H&E, original magnification ×100). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
Fig. 2 Pictomicrograph showing pancreatic tissue with islet cells (H&E, original magnification ×200).
cells with a round nucleus are poorly stained granular cytoplasm (Fig. 2). With the above findings, a diagnosis of pancreatic heterotopia was made. The presence of pancreatic tissue in an aberrant location manifests itself most frequently in the fourth and fifth decade. Although a developmental anomaly, it is rarely encountered in children [1,3]. The aberrant tissue is mostly located in the wall of the stomach, duodenum, jejunum, ileum, Meckel's diverticulum, gallbladder, bile ducts, spleen, omentum, and also in liver parenchyma. Its presence in the skin of the abdominal wall is extremely rare [1-3]. Preoperative identification of pancreatic heterotopia is difficult. Most of the cases reported in literature are an incidental finding in surgically resected specimens. Histologically, heterotopic pancreas can be divided into the following 4 types: (1) those comprised all cell types (total heterotopia), (2) those composed of ducts only (canalicular heterotopia), (3) those with acinar cells only (exocrine heterotopia), and (4) those composed of islet cells only (endocrine heterotopia) [3]. In our case, all cell types were present. The exact etiology of ectopic pancreatic tissue is unclear, but possible mechanisms proposed to explain the diversity of anatomical sites of occurrence include failure of the ventral pancreatic buds to undergo atrophy, aberrant
2058
Correspondence
migration/sequestration of ventral bud remnants, and metaplasia of multipotent endodermal cells. The embryological explanation of isolated pancreatic heterotopia in the skin below umbilicus is aberrant migration/sequestration of ventral bud remnants [4,5]. Complete surgical removal is suggested to avoid potential future complications such as pancreatitis, ulceration, cystic change, and pancreatic neoplasm either endocrine or exocrine [6].
Kalpalata Tripathy Pallavi Bhuyan Lity Mohanty Sujata Pukari Sitaram Mohapatra Department of Pathology S.C.B. Medical College Cuttack - 753007Orissa, India E-mail address: [email protected]
doi:10.1016/j.jpedsurg.2009.06.014
References [1] Tonkin RD, Field TE, Wykes PR. Pancreatic heterotopia as a cause of dyspepsia. Gut 1962;3:135-9. [2] Shim YT, Kin SY. Heterotopic gastric mucosa and pancreatic tissue in the skin of the abdominal wall. J Pediatr Surg 1992;27:1539-40. [3] Hammock L, Jorda M. Gastric endocrine pancreatic heterotopia—report of a case with histologic and immunohistochemical findings and review of the literature. Arch Pathol Lab Med 2002;126:464-7. [4] Willis J. Developmental disorders of gall bladder, extra-hepatic biliary tract and pancreas. In: Odze RD, Golddum RR, editors. Surgical pathology of GI tract, liver, biliary tract & pancreas, 2nd ed. Philadelphia: Saunders Elsevier; 2009. p. 812. [5] McKee PH, Calonje JE, Granter SR. Cutaneous cyst. In: Mc Kee PH, editor. Pathology of skin with clinical correlation, 3rd ed., Vol. 2. Mosby: Ethelcathers: Elsevier; 2005. p. 1681-2. [6] Lim PHC, Chang HC, Ho JMS. Transendoscopic removal of Heterotopic Pancreatic tissue in the stomach—a case report. Singapore Med J 1987;28(4):366-8.
Laparoscopic-percutaneous kidney biopsy in children—a new approach To the Editor, Percutaneous ultrasound-guided kidney biopsy is the method of choice in the pediatric population because it is a safe and reliable method. In the presence of coagulation disorders, renal artery aneurysm, solitary kidney, severe hypertension, and obesity, however, open biopsy would be preferred [1,2]. In these latter cases, we propose a new approach to kidney biopsy combining laparoscopy and percutaneous needle biopsy that may be a less invasive alternative to open biopsy [3].
Between February and November of 2007, 5 children (mean age, 8 years old; range, 1 year 10 months to 13 years 7 months) with coagulation disorders or previous failed percutaneous biopsy were prospectively assigned to laparoscopic-percutaneous kidney biopsy at our institution. The study was approved by the Ethics Committee at the Federal University of Juiz de Fora, and the subjects' families signed an informed consent to participate. Under general anesthesia, a cushion is placed under the right lumbar region to elevate the right flank to 45°. A small incision is made on the inferior margin of the umbilicus, and under direct vision, a 10-mm trocar is introduced in the abdominal cavity for laparoscopic visualization. Two additional 5-mm trocars are placed through small incisions in the right iliac region and just below the xiphoid for working ports for forceps and scissor. The right lobe of the liver is retracted, and minimal dissection of the retroperitoneum is done to expose the lower pole of the right kidney. Under direct vision, a truecut needle is introduced through the skin in the right flank and placed in the inferior pole of the kidney to acquire a biopsy specimen. The needle is removed, and a gauze is placed on the biopsy site and compressed to control bleeding. After the bleeding stops, we repeat the procedure for more renal fragments. In all patients, 4 fragments were obtained, 2 were sent for histologic analysis, and 2 for immunofluorescent studies. There were no intraoperative complications. After gauze compression of the biopsy site, all points of puncture stopped bleeding completely. The mean operative time was 35 minutes. At the conclusion of the biopsy and after awakening from anesthesia, all patients were sent to their room for 24 hours. Four patients had minimal abdominal pain the next day after surgery. One had more pain and required a longer stay in the hospital. Paracetamol was used for analgesia. The mean hospital stay was 33.5 hours. Four patients stayed only until the next morning (24 hours), and the patient who had increased abdominal pain stayed for 72 hours. Hematuria persisted for only 24 hours in all patients. There were 15 to 25 glomeruli per fragment, which gave the pathologist sufficient material for the diagnosis in all cases. A week after the procedure, a renal ultrasound is done to check for hematoma or other local complications. We found no sonographic evidence of bleeding or renal hematoma. When there are contraindications to performing an ultrasound-guided percutaneous biopsy, obtaining a biopsy specimen under direct vision can be accomplished by open flank incision, laparoscopy, or retroperitoneoscopy [4,5]. The choice of using laparoscopic or retroperitoneoscopic access depends mostly on the experience of the surgeon with both techniques. The advantages of these methods are that the surgeon has a direct view of the kidney to perform the biopsy and maintain hemostasis. Performing a renal biopsy using the percutaneous-laparoscopic technique demonstrated here has a number of advantages including using a minimally invasive laparoscopic procedure
www.elsevier.com/locate/jpedsurg
Correspondence
Pancreatic heterotopia in the skin of the abdominal wall To the Editor, Heterotopic pancreas is recognized throughout the gastrointestinal tract in various sites [1]. The location of the lesion in the skin of the abdominal wall is a rare occurrence; and this report in a one and half-year old child is probably the second such case to the best of our knowledge [2]. This may be found in all age groups, although the condition is only rarely encountered in children. A one-and-half-year-old child presented with a small cystic mass of 2 months duration, measuring 2.0 cm in diameter located superficially in the abdominal wall below the umbilicus. It was clinically diagnosed as urachal cyst. The lesion was excised, and the operative note described a cyst containing straw-colored fluid without any internal connections. The gross specimen comprised a thin elongated grayish white tissue with a firm nodular swelling at one end measuring 0.3 cm in diameter. On cut section, the nodule was solid and yellowish in appearance. Histopathologic study was done with H&E staining. Microscopic examination revealed a circumscribed lesion composed of solid nests of acini and ducts resembling normal pancreatic tissue (Fig. 1). Pancreatic islet cells were also identified as clusters of small
Fig. 1 Pictomicrograph showing solid nests of pancreatic acini and ducts (H&E, original magnification ×100). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
Fig. 2 Pictomicrograph showing pancreatic tissue with islet cells (H&E, original magnification ×200).
cells with a round nucleus are poorly stained granular cytoplasm (Fig. 2). With the above findings, a diagnosis of pancreatic heterotopia was made. The presence of pancreatic tissue in an aberrant location manifests itself most frequently in the fourth and fifth decade. Although a developmental anomaly, it is rarely encountered in children [1,3]. The aberrant tissue is mostly located in the wall of the stomach, duodenum, jejunum, ileum, Meckel's diverticulum, gallbladder, bile ducts, spleen, omentum, and also in liver parenchyma. Its presence in the skin of the abdominal wall is extremely rare [1-3]. Preoperative identification of pancreatic heterotopia is difficult. Most of the cases reported in literature are an incidental finding in surgically resected specimens. Histologically, heterotopic pancreas can be divided into the following 4 types: (1) those comprised all cell types (total heterotopia), (2) those composed of ducts only (canalicular heterotopia), (3) those with acinar cells only (exocrine heterotopia), and (4) those composed of islet cells only (endocrine heterotopia) [3]. In our case, all cell types were present. The exact etiology of ectopic pancreatic tissue is unclear, but possible mechanisms proposed to explain the diversity of anatomical sites of occurrence include failure of the ventral pancreatic buds to undergo atrophy, aberrant
2058
Correspondence
migration/sequestration of ventral bud remnants, and metaplasia of multipotent endodermal cells. The embryological explanation of isolated pancreatic heterotopia in the skin below umbilicus is aberrant migration/sequestration of ventral bud remnants [4,5]. Complete surgical removal is suggested to avoid potential future complications such as pancreatitis, ulceration, cystic change, and pancreatic neoplasm either endocrine or exocrine [6].
Kalpalata Tripathy Pallavi Bhuyan Lity Mohanty Sujata Pukari Sitaram Mohapatra Department of Pathology S.C.B. Medical College Cuttack - 753007Orissa, India E-mail address: [email protected]
doi:10.1016/j.jpedsurg.2009.06.014
References [1] Tonkin RD, Field TE, Wykes PR. Pancreatic heterotopia as a cause of dyspepsia. Gut 1962;3:135-9. [2] Shim YT, Kin SY. Heterotopic gastric mucosa and pancreatic tissue in the skin of the abdominal wall. J Pediatr Surg 1992;27:1539-40. [3] Hammock L, Jorda M. Gastric endocrine pancreatic heterotopia—report of a case with histologic and immunohistochemical findings and review of the literature. Arch Pathol Lab Med 2002;126:464-7. [4] Willis J. Developmental disorders of gall bladder, extra-hepatic biliary tract and pancreas. In: Odze RD, Golddum RR, editors. Surgical pathology of GI tract, liver, biliary tract & pancreas, 2nd ed. Philadelphia: Saunders Elsevier; 2009. p. 812. [5] McKee PH, Calonje JE, Granter SR. Cutaneous cyst. In: Mc Kee PH, editor. Pathology of skin with clinical correlation, 3rd ed., Vol. 2. Mosby: Ethelcathers: Elsevier; 2005. p. 1681-2. [6] Lim PHC, Chang HC, Ho JMS. Transendoscopic removal of Heterotopic Pancreatic tissue in the stomach—a case report. Singapore Med J 1987;28(4):366-8.
Laparoscopic-percutaneous kidney biopsy in children—a new approach To the Editor, Percutaneous ultrasound-guided kidney biopsy is the method of choice in the pediatric population because it is a safe and reliable method. In the presence of coagulation disorders, renal artery aneurysm, solitary kidney, severe hypertension, and obesity, however, open biopsy would be preferred [1,2]. In these latter cases, we propose a new approach to kidney biopsy combining laparoscopy and percutaneous needle biopsy that may be a less invasive alternative to open biopsy [3].
Between February and November of 2007, 5 children (mean age, 8 years old; range, 1 year 10 months to 13 years 7 months) with coagulation disorders or previous failed percutaneous biopsy were prospectively assigned to laparoscopic-percutaneous kidney biopsy at our institution. The study was approved by the Ethics Committee at the Federal University of Juiz de Fora, and the subjects' families signed an informed consent to participate. Under general anesthesia, a cushion is placed under the right lumbar region to elevate the right flank to 45°. A small incision is made on the inferior margin of the umbilicus, and under direct vision, a 10-mm trocar is introduced in the abdominal cavity for laparoscopic visualization. Two additional 5-mm trocars are placed through small incisions in the right iliac region and just below the xiphoid for working ports for forceps and scissor. The right lobe of the liver is retracted, and minimal dissection of the retroperitoneum is done to expose the lower pole of the right kidney. Under direct vision, a truecut needle is introduced through the skin in the right flank and placed in the inferior pole of the kidney to acquire a biopsy specimen. The needle is removed, and a gauze is placed on the biopsy site and compressed to control bleeding. After the bleeding stops, we repeat the procedure for more renal fragments. In all patients, 4 fragments were obtained, 2 were sent for histologic analysis, and 2 for immunofluorescent studies. There were no intraoperative complications. After gauze compression of the biopsy site, all points of puncture stopped bleeding completely. The mean operative time was 35 minutes. At the conclusion of the biopsy and after awakening from anesthesia, all patients were sent to their room for 24 hours. Four patients had minimal abdominal pain the next day after surgery. One had more pain and required a longer stay in the hospital. Paracetamol was used for analgesia. The mean hospital stay was 33.5 hours. Four patients stayed only until the next morning (24 hours), and the patient who had increased abdominal pain stayed for 72 hours. Hematuria persisted for only 24 hours in all patients. There were 15 to 25 glomeruli per fragment, which gave the pathologist sufficient material for the diagnosis in all cases. A week after the procedure, a renal ultrasound is done to check for hematoma or other local complications. We found no sonographic evidence of bleeding or renal hematoma. When there are contraindications to performing an ultrasound-guided percutaneous biopsy, obtaining a biopsy specimen under direct vision can be accomplished by open flank incision, laparoscopy, or retroperitoneoscopy [4,5]. The choice of using laparoscopic or retroperitoneoscopic access depends mostly on the experience of the surgeon with both techniques. The advantages of these methods are that the surgeon has a direct view of the kidney to perform the biopsy and maintain hemostasis. Performing a renal biopsy using the percutaneous-laparoscopic technique demonstrated here has a number of advantages including using a minimally invasive laparoscopic procedure