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World Journal of Clinical Cases Dec 2023Cholecystoenteric fistula (CEF) involves the formation of a spontaneous anomalous tract between the gallbladder and the adjacent gastrointestinal tract. Chronic...
BACKGROUND
Cholecystoenteric fistula (CEF) involves the formation of a spontaneous anomalous tract between the gallbladder and the adjacent gastrointestinal tract. Chronic gallbladder inflammation can lead to tissue necrosis, perforation, and fistulogenesis. The most prevalent cause of CEF is chronic cholelithiasis, which rarely results from malignancy. Because the symptoms and laboratory findings associated with CEF are nonspecific, the condition is often misdiagnosed, presenting a challenge to the surgeon when detected intraoperatively. Therefore, a preoperative diagnosis of CEF is crucial.
CASE SUMMARY
We present the case of a 57-year-old male with advanced gallbladder cancer (GBC) who arrived at the emergency room with persistent vomiting, abdominal pain, and diarrhea. An abdominopelvic computed tomography scan revealed a contracted gallbladder with bubbles in the fundus connected to the second portion of the duodenum and transverse colon. We suspected that GBC had invaded the adjacent gastrointestinal tract through a cholecystoduodenal fistula (CDF) or a cholecystocolonic fistula (CCF). He underwent multiple examinations, including esophagogastroduodenoscopy, an upper gastrointestinal series, colonoscopy, and magnetic resonance cholangiopancreatography; the results of these tests confirmed a diagnosis of synchronous CDF and CCF. The patient underwent a Roux-en-Y gastrojejunostomy and loop ileostomy to address the severe adhesions that were previously observed to cover the second portion of the duodenum and hepatic flexure of the colon. His symptoms improved with supportive treatment while hospitalized. He initiated oral targeted therapy with lenvatinib for further anticancer treatment.
CONCLUSION
The combination of imaging and surgery can enhance preoperative diagnosis and alleviate symptoms in patients with GBC complicated by CEF.
PubMed: 38188217
DOI: 10.12998/wjcc.v11.i36.8519 -
ACG Case Reports Journal Mar 2024Pancreatic tuberculosis (TB) warrants heightened suspicion in individuals with pancreatic lesions and risk factors such as HIV, organ transplantation, or pertinent...
Pancreatic tuberculosis (TB) warrants heightened suspicion in individuals with pancreatic lesions and risk factors such as HIV, organ transplantation, or pertinent immigration history. We present a 38-year-old man who presented with hemodynamically unstable gastrointestinal bleeding. He was found to have pancreatic TB complicated by a duodenal ulcer with fistula. Following 1 month of antitubercular therapy, he experienced complete resolution of symptoms, healing of the duodenal ulcer, closure of the fistulous tract, and a decrease in the size of the pancreatic lesion as observed on imaging. Our case highlights the importance of early diagnosis and treatment of pancreatic TB.
PubMed: 38524261
DOI: 10.14309/crj.0000000000001318 -
Journal of the College of Physicians... Dec 2023To identify predictive factors associated with the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) in an increasingly... (Observational Study)
Observational Study
OBJECTIVE
To identify predictive factors associated with the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) in an increasingly geriatric population.
STUDY DESIGN
Observational study. Place and Duration of the Study: Department of General Surgery, Inonu University, Malatya, Turkey, from January 2010 to April 2022.
METHODOLOGY
Demographic and clinicopathological data of 74 geriatric patients who underwent PD for periampullary tumours in the clinic at Inonu University were retrieved from the patient database. POPF was defined and categorised based on the guidelines established by the International Study Group for Pancreatic Surgery (ISGPS). The patients were stratified into two cohorts of POPF and no POPF. Univariate and multivariate analyses were conducted to compare variables between the two groups.
RESULTS
The median age of the patient population was 72 (65-92) years, and 51 (68.9%) individuals were male. Among the 74 patients, 35 (47.3%) experienced POPF. In the multivariate analysis, hypertension (HT, p=0.012), Wirsung diameter <3.5 mm (p<0.01), and pancreaticojejunostomy (PJ, p=0.022) emerged as independent risk factors for POPF.
CONCLUSION
In the context of geriatric patients undergoing PD, HT, intraoperative wirsung diameter <3.5 mm, and PJ were identified as independent risk factors for POPF. These findings can guide the adoption of safer techniques in preoperative and intraoperative evaluations, as well as in postoperative follow-ups of patients presenting with these risk factors.
KEY WORDS
Elderly, Whipple procedure, Anastomotic leakage, Predictive factor, Postoperative pancreatic fistula, Pancreatoduodenectomy.
Topics: Humans; Male; Aged; Aged, 80 and over; Female; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreas; Pancreaticojejunostomy; Risk Factors; Duodenal Neoplasms; Postoperative Complications; Retrospective Studies
PubMed: 38062603
DOI: 10.29271/jcpsp.2023.12.1439 -
Annali Italiani Di Chirurgia 2024The growing elderly population is facing an increasing risk of cancers, consequently raising the pancreatic cancer surgery rate. This study aimed to determine whether...
AIM
The growing elderly population is facing an increasing risk of cancers, consequently raising the pancreatic cancer surgery rate. This study aimed to determine whether advanced age is a risk factor for morbidity and mortality following pancreaticoduodenectomy (PD) for periampullary tumors.
MATERIALS AND METHODS
The present study included 90 patients who underwent PD for periampullary tumors. Patients were divided into two age-related groups, including those aged 60-74 years (n = 60) (Group 1) and those aged ≥75 years (n = 30) (Group 2). Each patient's characteristics, perioperative features, morbidity, and long-term results were evaluated retrospectively.
RESULTS
In both univariate and multivariate logistic regression analyses, old age (≥75 years) was not a risk factor for morbidity and hospital mortality. The multivariate analysis demonstrated that male gender (p = 0.008), pancreatic duct diameter (<3 mm) (p < 0.001), and length of hospital stay (p = 0.005) were independent risk factors for pancreatic fistula post-operation and reoperation. Additionally, hospital mortality was significantly associated with reoperation (p = 0.011). The overall median survival was 27 ± 4.1 (18.8-35.1) months. Lymph node positivity (p < 0.001), neural tumor invasion (p = 0.026), and age ≥75 years (p = 0.045) were risk factors affecting the overall survival rate. Moreover, there was no statistically significant difference in terms of PD rates during the Coronavirus disease-19 (COVID-19) period among groups, and PD during this period was not related to the occurrence of pancreatic fistula.
CONCLUSION
PD can be performed effectively in selected elderly patients with tolerable morbidity and mortality rates.
Topics: Humans; Pancreaticoduodenectomy; Aged; Male; Female; Middle Aged; Retrospective Studies; Ampulla of Vater; Pancreatic Neoplasms; Risk Factors; Common Bile Duct Neoplasms; Hospital Mortality; Postoperative Complications; Age Factors; Aged, 80 and over; Time Factors; Length of Stay; Pancreatic Fistula; Reoperation
PubMed: 38684489
DOI: 10.62713/aic.3380 -
Surgical Case Reports Sep 2023Pancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can...
BACKGROUND
Pancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.
CASE PRESENTATION
The patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.
CONCLUSION
In children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.
PubMed: 37665533
DOI: 10.1186/s40792-023-01735-3 -
Indian Journal of Gastroenterology :... Jun 2024Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) offers a safe and minimally invasive alternative for percutaneous cholecystostomy (PCC) in acute...
BACKGROUND
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) offers a safe and minimally invasive alternative for percutaneous cholecystostomy (PCC) in acute cholecystitis patients with high-surgical risk. Additionally, EUS-GBD serves as a rescue biliary drainage in malignant distal biliary obstruction. Despite its widespread application, data within the Indian context remains sparse. This study aims to report the outcomes of EUS-GBD through the first multi-center study from India.
METHODS
We retrospectively analyzed patients undergoing EUS-GBD at six tertiary care centers of India from March 2022 to November 2023. EUS-GBD was performed by free hand or over-the-guidewire technique with lumen-apposing metal stent (LAMS) or large caliber metal stent (LCMS). The primary outcome was technical success (defined as successful deployment of stent between gallbladder and stomach/duodenal lumen). The secondary outcomes were clinical success (defined as resolution of symptoms of acute cholecystitis and more than > 50% reduction in bilirubin level within two weeks in distal biliary obstruction), adverse event rate, 30-day mortality rate and 90-day reintervention rate.
RESULTS
Total 29 patients (mean age 65.86 ± 12.91, 11 female) underwent EUS-GBD. The indication for EUS-GBD were acute cholecystitis (79.31%) and rescue biliary drainage for malignant distal biliary obstruction (20.69%). LAMS was deployed in 92.86%, predominantly by free-hand technique (78.57%). Technical and clinical success rates were 96.55% and 82.75%, respectively. Adverse events occurred in 27.59% patients, with severe adverse events (bile leak and bleeding) being uncommon (10%). Both 30-day mortality rate and 90-day reintervention rate were 13.79% in patients. Cholecysto-duodenal fistula facilitated cholecystoscopic intervention and stone removal in one patient and transgastric EUS-GBD did not hamper bilio-enteric anastomosis during Whipple surgery in two patients.
CONCLUSION
EUS-GBD is a safe and effective technique for managing acute cholecystitis in high-risk patients and for biliary drainage in cases with malignant distal biliary obstruction.
PubMed: 38902473
DOI: 10.1007/s12664-024-01614-1 -
Updates in Surgery Apr 2024The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive...
The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.
Topics: Humans; Pancreatitis, Acute Necrotizing; Mesocolon; Acute Disease; Laparoscopy; Minimally Invasive Surgical Procedures; Pancreatic Fistula; Drainage; Debridement; Treatment Outcome
PubMed: 38429596
DOI: 10.1007/s13304-024-01773-y -
Zhonghua Yi Xue Za Zhi Mar 2024To explore the effectiveness of minimally invasive surgical treatment for pancreatic acinar cell carcinoma (PACC). Six patients with PACC diagnosed in Peking...
To explore the effectiveness of minimally invasive surgical treatment for pancreatic acinar cell carcinoma (PACC). Six patients with PACC diagnosed in Peking University Third Hospital from January 2010 to September 2022 were retrospectively selected. Preoperative evaluation was performed on whether the lesions were eligible for surgery, including whether radical resection of liver metastases could be performed. Laparoscopic or Da Vinci robot-assisted resection was performed on six patients, and spleen retention was determined according to the original lesions and the relationship with peripheral blood vessels and tissues, while simultaneous resection was performed on cases of peripheral organ tissue invasion. The patients' basic information, preoperative general conditions, preoperative diagnosis and tumor stage, minimally invasive surgery methods, postoperative complications, pathological results, tumor stage and follow-up data were collected and analyzed to explore the effectiveness of minimally invasive surgery. Among the six patients, four were males and two were females, with the age of 25-69 years. Five patients had abdominal pain and distension before surgery, five patients had tumors located at the tail of the pancreatic body, and one patient had tumors located at the head of the pancreas. Preoperative imaging (enhanced CT and MRI) was performed to measure the tumor diameter (2.8-10.0 cm). Tumor markers were elevated in two patients before surgery, and six patients underwent surgery through laparoscopy or robotic platform. No complications such as postoperative pancreatic fistula and bleeding were clinically relevant during and after surgery. There were two cases with concurrent or heterochronous liver metastasis, two cases with lymph node metastasis and nodular metastasis, four cases with tumor invasion of surrounding organs (stomach, spleen or duodenum), and three cases with vascular cancer thrombi. The follow-up time of the six patients was 12 to 165 months, and one patient underwent three operations due to postoperative liver metastasis and residual pancreatic recurrence, and the results were satisfactory. All the six patients survived at the last follow-up. PACC is prone to invade the surrounding organs, and has a large tumor diameter. Radical surgery for PACC can be completed through minimally invasive surgery, and satisfactory oncology prognosis can be obtained. In addition, some PACC patients with recurrence and metastasis can still be treated by surgery.
Topics: Male; Female; Humans; Adult; Middle Aged; Aged; Retrospective Studies; Carcinoma, Acinar Cell; Pancreatic Neoplasms; Laparoscopy; Minimally Invasive Surgical Procedures; Liver Neoplasms
PubMed: 38514344
DOI: 10.3760/cma.j.cn112137-20231008-00675 -
Zhonghua Wai Ke Za Zhi [Chinese Journal... May 2024To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the...
To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the treatment of borderline and benign diseases of the pancreatic head. This is a retrospective cohort study. Perioperative data from 87 patients with non-malignant pancreatic head diseases who underwent LDPPHR or LPD were retrospectively collected in the Department of Biliary-Pancreatic Surgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2020 to December 2022. There were 49 male and 38 female patients with an age of 57.0(16.5) years (range: 20 to 75 years). Forty patients underwent LDPPHR and 47 patients underwent LPD. Quantitative data following a normal distribution were compared using Student's -test, while quantitative data not following a normal distribution were compared using the Mann-Whitney test. Comparisons of categorical or ordinal variables were made using test or Fisher's exact test. Logistic regression analysis was used to estimate the risk factors associated with the rate of complications. There were no statistically significant differences between the LDPPHR group and the LPD group in terms of reoperation rate,total hospital stay duration,postoperative hospital stay duration,90-day mortality rate,30-day and 90-day readmission rates,and 2-year tumor recurrence rate (all >0.05). The complication rate was higher in the LDPPHR group compared to the LPD group(32 cases (80.0%) 24 cases (51.1%),=7.89,=0.005),but there was no difference in the rate of Clavien-Dindo classification of surgical complications≥Ⅲ between the two groups(4 cases (10.0%) 6 cases (12.8%), <0.01, =0.947). Additionally,the rate of delayed gastric emptying (DGE) was higher in the LDPPHR group compared to the LPD group (=10.79,=0.001),but there was no statistically significant difference in the rate of B,C grade DGE between the two groups (=0.48, =0.487). There were no statistically significant differences in the rates of postoperative pancreatic fistula,bile leakage,post-pancreatectomy hemorrhage,intra-abdominal infection,and pulmonary infection between the two groups (all >0.05). The results of the univariate logistic regression analysis showed that LDPPHR (compared to LPD, =3.83, 95%: 1.46 to 10.04, =2.73,=0.006) and preoperative biliary stent placement (compared to non-use of biliary stent, =5.30, 95%: 1.13 to 25.00, =2.11, =0.035) were risk factors for the complication rate,but neither was an independent risk factor for complication rate (all >0.05). The preliminary results suggest that LDPPHR can achieve perioperative safety and effectiveness comparable to LPD.
PubMed: 38808434
DOI: 10.3760/cma.j.cn112139-20240317-00130 -
Chirurgie (Heidelberg, Germany) Jun 2024Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple... (Review)
Review
Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.
Topics: Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Neuroendocrine Tumors; Precancerous Conditions; Pancreatic Cyst; Postoperative Complications
PubMed: 38568302
DOI: 10.1007/s00104-024-02070-5