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La technique d'une DPC pour adénocarcinome a évolué ces dernières années tant au niveau sécurité qu'au niveau carcinologique mais cela n'a pas suffit à faire progresser la survie. On peut se demander si la modification de la technique chirurgicale pourrait avoir un impact significatif sur la survie.A) Nous avons recherché, sur 23 pièces de DPC encrées, la présence de la mutation K-ras au niveau de la marge veineuse affirmée R0 en analyse histologique : 13 spécimens (groupe kras+) exprimaient une mutation K-ras au sein de la marge veineuse versus 10 spécimens (groupe kras-) ne l'exprimant pas. Les tumeurs des 2 groupes étaient comparables (taille, envahissement ganglionnaire, engainement périnerveux…). La survie globale à 1 an et 3 ans des groupes kras- versus kras+ étaient de 80% versus 84,6% et 16,7% versus 0% (p=0,03), respectivement. Les médianes de survie des groupes kras- versus kras+ étaient de 24 mois versus 16 mois (p=0,04), respectivement.B) Nous avons comparé, après appariement, 19 patients ayant eu une DPC avec résection « par excès » de la veine porte (groupe VP) avec 19 patients ayant eu une DPC sans résection de la veine porte (groupe contrôle). Les survies médianes et à 3 ans du groupe VP versus groupe contrôle étaient 42 mois versus 22 mois (p=0,04) et 60% versus 31% (p=0,03), respectivement.En conclusion, notre travail a montré qu'au-delà de la marge déterminée par le chirurgien pendant la chirurgie, de celle de l'anatomopathologiste déterminée par l'analyse microscopique, il existait une marge génique. La résection systématique de la veine porte semblait bénéfique car elle permettait sans doute de passer au-delà de cette marge génique. / Pancreticoduodenectomy (PD) for adenocarcinoma was safer during the last decades but did not improve survival. We sought to determine if technical changes during PD could improve survival.A) In a first study, we determine the presence of K-ras mutation in the venous margin of 23 PD's specimens. Thirteen specimens had K-ras mutation (kras+ group) and 10 specimens did not (kras- group). Except K-ras mutation status, tumors of the 2 groups were not different when comparing major histological findings (margin status, lymph node invasion, perineural invasion…). Overall 1- and 3-years survival of patients of kras- group versus kras+ group were 80% versus 84,6% and 16,7% versus 0% (p=0,03), respectively. Median survival of patients of kras- group versus kras+ group were 24 months versus 16 months (p=0,04), respectively.B) In a second study, we compared 19 patients with “excessive” portal vein resection during PD (PV group) with 19 matched patients who underwent PD without venous resection (control group). Median survival of patients of PV group versus control group were 42 months versus 22 months (p=0,04), respectively.In conclusion, we showed that the « genic margin » concept was consistent. Systematic portal vein resection could avoid positive genic margin and might be benefic for patient who underwent PD for resecable adenocarcinoma.

To reduce the risk of pancreatic fistula after pancreatectomy, a satisfactory blood flow at the pancreatic stump is considered crucial. Our group has developed and validated a real-time computational imaging analysis of tissue perfusion, using fluorescence imaging, the fluorescence-based enhanced reality (FLER). Hyperspectral imaging (HSI) is another emerging technology, which provides tissue-specific spectral signatures, allowing for perfusion quantification. Both imaging modalities were employed to estimate perfusion in a porcine model of partial pancreatic ischemia. Perfusion quantification was assessed using the metrics of both imaging modalities (slope of the time to reach maximum fluorescence intensity and tissue oxygen saturation (StO2), for FLER and HSI, respectively). We found that the HSI-StO2 and the FLER slope were statistically correlated using the Spearman analysis (R = 0.697; p = 0.013). Local capillary lactate values were statistically correlated to the HSI-StO2 and to the FLER slope (R = −0.88; p < 0.001 and R = −0.608; p = 0.0074). HSI-based and FLER-based lactate prediction models had statistically similar predictive abilities (p = 0.112). Both modalities are promising to assess real-time pancreatic perfusion. Clinical translation in human pancreatic surgery is currently underway.

O objetivo do presente estudo é avaliar os fatores clínico-patológicos envolvidos na sobrevida dos pacientes portadores de adenocarcinoma pancreático submetidos à ressecção cirúrgica. Foram estudados retrospectivamente 56 pacientes, sendo 32(57,1%) do sexo feminino e 24 (42,8%) do masculino com idade média de 58,1 anos. A duodenopancreatectomia com preservação do piloro foi realizada em 51,8%, seguida da gastroduodenopancreatectomia (41,1%), pancreatectomia total (3,6%) e pancreatectomia corpo-caudal (3,6%). Quatro pacientes eram do estádio IA, sete do IB, 12 do IIA, 29 do IIB e dois do III. A sobrevida média foi de 20,7 meses. Concluiu-se que sexo, tempo de pro-trombina reduzido, ressecção da veia porta, diferenciação tumoral e invasão peri-neural estão associados com a sobrevida / The aim of the present study is to correlate clinical and pathological finding with survival in patients with pancreatic adenocarcinoma treated with surgical resection. Fifty six patients ressected were studied retrospectively. There were 32 females (57,1%) and 24 males (42,8%) with mean age of 58,1 years. Pylorus preserving duodenopancreatectomy were performed in 51,8%, followed by classical duodenopancreatectomy (41,1%), distal pancreatectomy (3,6%) and total pancreatectomy (3,6%). Four patients were stage IA, seven stage IB, 12 stage IIA, 29 stage IIB and two stage III. Mean survival was 20,7 months. It was concluded that sex, pro-trombin time reduction, portal vein resection, tumor differentiation and peri-neural invasion are statistically associated with survival

O objetivo do presente estudo é avaliar os fatores clínico-patológicos envolvidos na sobrevida dos pacientes portadores de adenocarcinoma pancreático submetidos à ressecção cirúrgica. Foram estudados retrospectivamente 56 pacientes, sendo 32(57,1%) do sexo feminino e 24 (42,8%) do masculino com idade média de 58,1 anos. A duodenopancreatectomia com preservação do piloro foi realizada em 51,8%, seguida da gastroduodenopancreatectomia (41,1%), pancreatectomia total (3,6%) e pancreatectomia corpo-caudal (3,6%). Quatro pacientes eram do estádio IA, sete do IB, 12 do IIA, 29 do IIB e dois do III. A sobrevida média foi de 20,7 meses. Concluiu-se que sexo, tempo de pro-trombina reduzido, ressecção da veia porta, diferenciação tumoral e invasão peri-neural estão associados com a sobrevida / The aim of the present study is to correlate clinical and pathological finding with survival in patients with pancreatic adenocarcinoma treated with surgical resection. Fifty six patients ressected were studied retrospectively. There were 32 females (57,1%) and 24 males (42,8%) with mean age of 58,1 years. Pylorus preserving duodenopancreatectomy were performed in 51,8%, followed by classical duodenopancreatectomy (41,1%), distal pancreatectomy (3,6%) and total pancreatectomy (3,6%). Four patients were stage IA, seven stage IB, 12 stage IIA, 29 stage IIB and two stage III. Mean survival was 20,7 months. It was concluded that sex, pro-trombin time reduction, portal vein resection, tumor differentiation and peri-neural invasion are statistically associated with survival

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23082号 / 医博第4709号 / 新制||医||1049(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 長船 健二, 教授 妹尾 浩, 教授 村川 泰裕 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

INTRODUÇÃO: Após a cirurgia pancreática, a função exócrina é determinada pela extensão da ressecção e a quantidade de tecido pancreático remanescente, sendo recomendável a avaliação da insuficiência pancreática exócrina (IPE) em todos os pacientes. A reposição de enzimas pancreáticas é o pilar do tratamento da IPE, pois melhora a absorção de gordura, diminui os sintomas relacionados com a má absorção e melhora a qualidade de vida (QV). OBJETIVO: Sabendo que o ajuste da dose de enzimas pancreáticas é realizado com base nos sinais clínicos relatados pelo paciente, o presente estudo visa aprofundar a avaliação clínica destes e avaliar o atual protocolo de tratamento, mantendo ou melhorando a QV dos pacientes. MÉTODOS: Estudo transversal em que foram avaliados adultos com histórico de ressecção pancreática há 6 meses ou mais. No tempo 1 foi realizada avaliação nutricional antropométrica e recordatório alimentar, avaliação clínica de qualidade de vida (questionário SF-36), investigação hábitos intestinais e exames laboratoriais. No tempo 2 foi realizada nova consulta para discussão dos resultados e orientação nutricional individualizada. Para análise de correlações foi usado o teste de Pearson, para associações o teste de Fisher e para comparação de médias o teste Mann-Whitney. RESULTADOS: Foram avaliados 39 pacientes, 22 (56,4%) do sexo feminino; 33 (84,6%) >=60 anos; tempo pós operatório 14,1± 6,8 anos; exames bioquímicos: em todas as dosagens a maioria dos pacientes apresenta resultados dentro dos valores de referência, mas há alta prevalência de deficiência de vitaminas lipossolúveis; os pacientes têm bom estado nutricional já que grande parte apresenta eutrofia segundo o IMC (46,1%) e segundo a porcentagem de gordura (35,9%); no geral não relatam sintomas gastrointestinais adversos: 61,5% com fezes formadas, 53,8% sem dor abdominal, 84,6% sem esteatorreia; adequação no consumo de macronutrientes: 51,3% consumo adequado de carboidratos e lipídios, e 64,1% de consumo excessivo de proteínas; correlações positivas: a dose de enzimas se correlaciona com a dor (p= 0,004) e o IMC (p= 0,009), ou seja, pacientes que relatam mais dor e que pesam mais são os que recebem as maiores doses de enzimas pancreáticas; correlações negativas: capacidade funcional e parâmetros de avaliação nutricional como IMC (p=0,004), e porcentagem de gordura (p=0,028), e também parâmetros clínicos como a dose de enzimas (p=0,022) e o número de evacuações por dia (p=0,024); associações: a inadequação do consumo de lipídios na dieta está associada com importantes sintomas gastrointestinais como a consistência amolecida das fezes (p=0,005) e flatulência (p=0,012) e ressalta a importância da orientação nutricional aos pacientes em reposição de enzimas pancreáticas. CONCLUSÃO: A maioria dos pacientes apresentou bons resultados de exames bioquímicos, qualidade de vida, consumo de macronutrientes, estado nutricional e sintomas gastrointestinais. Observaram-se importantes correlações e associações que demonstram que o estado nutricional, o consumo alimentar e a dose de enzimas interferem nos sintomas gastrointestinais e na auto-percepção de qualidade de vida dos pacientes. Sendo assim, o atual protocolo é válido, mas deve ser associado a orientação nutricional individualizada / BACKGROUND: After pancreatic surgery, exocrine function is determined by the extent of resection and the amount of remaining pancreatic tissue, and all patients should be evaluated for exocrine pancreatic insufficiency (EPI). Pancreatic enzyme replacement is the mainstay of EPI treatment, since it improves fat absorption, reduces symptoms related to malabsorption and improves quality of life (QoL). OBJECTIVE: Knowing that the adjustment of pancreatic enzymes dose is based on the clinical signs reported by the patient, the present study aims to deepen the clinical evaluation and to evaluate the current protocol of treatment, maintaining or improving patients quality of life. METHODS: A cross-sectional study in which adults were evaluated 6 months or more after pancreatic resection. At time 1, anthropometric evaluation and food recall, clinical evaluation of quality of life (SF-36 questionnaire), intestinal habits and laboratory tests were performed. At time 2 a new consultation was conducted to discuss the results and to provide individualized nutritional guidance. For the correlations analysis the Pearson test was used, for associations the Fisher test and for comparison of means the Mann-Whitney test. RESULTS: 39 patients were evaluated, 22 (56.4%) female; 33 (84.6%) >= 60 years; Time after surgery 14.1 ± 6.8 years; Biochemical tests: at all dosages most patients present results within the reference values, but there is a high prevalence of fat-soluble vitamins deficiency; The patients have good nutritional status since a great part presents eutrophy according to the BMI (46.1%) and according to the percentage of body fat (35.9%); In general they do not report adverse gastrointestinal symptoms: 61.5% with feces formed, 53.8% without abdominal pain, 84.6% without steatorrhea; Adequacy in macronutrient consumption: 51.3% adequate consumption of carbohydrates and lipids, and 64.1% excessive consumption of proteins; Positive correlations: enzyme dose correlates with pain (p = 0.004) and BMI (p = 0.009); that is, patients who report more pain and who weigh more are those who receive the highest doses of pancreatic enzymes; Negative correlations: functional capacity and nutritional assessment parameters such as BMI (p = 0.004), and body fat percentage (p = 0.028), as well as clinical parameters such as enzyme dose (p = 0.022) and number of bowel movements per day p=0.024); Associations: the dietary lipid consumption inadequacy is associated with important gastrointestinal symptoms such as soft stool consistency (p=0.005) and flatulence (p=0.012), and emphasizes the importance of nutritional guidance to patients on pancreatic enzyme replacement therapy. CONCLUSION: Most patients presented good results of biochemical tests, quality of life, macronutrient consumption, nutritional status and gastrointestinal symptoms. Significant correlations and associations have been observed that evidence that nutritional status, food intake and enzyme dose interferes with gastrointestinal symptoms and self-perceived quality of life of patients. Therefore, the current protocol is valid, but should be associated with individualized nutritional guidance

<p>Protein tyrosine kinases play an important role in the regulation of various cellular processes such as</p><p>growth, differentiation and survival. GTK, a novel SRC-like cytoplasmic tyrosine kinase, was recently cloned from a mouse insulinoma cell line and the present work was conducted in order to find a biological function of GTK in insulin producing and neuronal cells. It was observed that kinase active GTK-mutants, expressed in RINm5F cells, transferred to the cell nucleus and increased the levels of the cell cycle regulatory protein p27^KIP1, reduced cell growth and stimulated glucagon mRNA expression. Furthermore, wild type GTK induces neurite outgrowth in the rat adrenal pheochromocytoma PC12 cell line, through activation of the RAP1-pathway, suggesting a role of GTK for cell differentiation. Studies using transgenic mice, expressing GTK under the control of the rat insulin 1 promoter, demonstrated a dual role of GTK for β-cell growth: Whereas GTK increases the β-cell mass and causes enhanced β-cell proliferation in response to partial pancreatectomy it also induced β-cell death in response to proinflammatory cytokines and impaired the glucose tolerance in mice treated with the β-cell toxin streptozotocin suggesting a possible role of GTK for β-cell destruction in Type 1 diabetes. We have also observed that GTK-transgenic islets and GTK-expressing RINm5F cells exhibit a reduced insulininduced activation of the insulin receptor substrate (IRS-1 and IRS-2)-pathways, partly due to an increased basal activity of these. GTK was found to associate with and phosphorylate the SH2 domain adapter protein SHB, which could explain many of the GTK-dependent effects both in vitro and in vivo. In summary, the present work suggests that the novel tyrosine kinase GTK is involved in various signal transduction pathways, regulating different cellular responses, such as proliferation, differentiation and survival.</p>

Protein tyrosine kinases play an important role in the regulation of various cellular processes such as growth, differentiation and survival. GTK, a novel SRC-like cytoplasmic tyrosine kinase, was recently cloned from a mouse insulinoma cell line and the present work was conducted in order to find a biological function of GTK in insulin producing and neuronal cells. It was observed that kinase active GTK-mutants, expressed in RINm5F cells, transferred to the cell nucleus and increased the levels of the cell cycle regulatory protein p27KIP1, reduced cell growth and stimulated glucagon mRNA expression. Furthermore, wild type GTK induces neurite outgrowth in the rat adrenal pheochromocytoma PC12 cell line, through activation of the RAP1-pathway, suggesting a role of GTK for cell differentiation. Studies using transgenic mice, expressing GTK under the control of the rat insulin 1 promoter, demonstrated a dual role of GTK for β-cell growth: Whereas GTK increases the β-cell mass and causes enhanced β-cell proliferation in response to partial pancreatectomy it also induced β-cell death in response to proinflammatory cytokines and impaired the glucose tolerance in mice treated with the β-cell toxin streptozotocin suggesting a possible role of GTK for β-cell destruction in Type 1 diabetes. We have also observed that GTK-transgenic islets and GTK-expressing RINm5F cells exhibit a reduced insulininduced activation of the insulin receptor substrate (IRS-1 and IRS-2)-pathways, partly due to an increased basal activity of these. GTK was found to associate with and phosphorylate the SH2 domain adapter protein SHB, which could explain many of the GTK-dependent effects both in vitro and in vivo. In summary, the present work suggests that the novel tyrosine kinase GTK is involved in various signal transduction pathways, regulating different cellular responses, such as proliferation, differentiation and survival.