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Cureus Apr 2024Black pleural effusions (BPEs) are an exceedingly rare class of exudative effusions of unexplored causality. Their characteristic pitch-black coloring and striking first...
Black pleural effusions (BPEs) are an exceedingly rare class of exudative effusions of unexplored causality. Their characteristic pitch-black coloring and striking first appearance upon thoracocentesis make them a bewildering occurrence even for seasoned physicians. Forming a free-from-error diagnostic work-up can be arduous and largely depends on thorough history-taking, deliberate imaging studies, and the correct biochemical profile. The upcoming article aims to raise awareness of this pathology by presenting our experience with a BPE after an episode of acute-on-chronic (ACP) pancreatitis and the confounding route to achieving the correct diagnosis and forming the precise therapeutic approach to this scenario. Keeping in mind that this is not a common clinical case, we strive to dispel some misconceptions and thus avoid any subsequent complications and delays in diagnosis when treating this type of effusions and their underlying pathology.
PubMed: 38770474
DOI: 10.7759/cureus.58687 -
Asian Journal of Surgery May 2024
PubMed: 38762416
DOI: 10.1016/j.asjsur.2024.05.109 -
International Journal of Surgery Case... Jun 2024Pancreaticopleural fistula is a rare complication most associated with alcohol-induced chronic pancreatitis. This usually presents with chest symptoms instead of...
INTRODUCTION
Pancreaticopleural fistula is a rare complication most associated with alcohol-induced chronic pancreatitis. This usually presents with chest symptoms instead of abdominal ones. Diagnosis requires a high index of suspicion in patients with pancreatitis and persistent pleural effusions.
PRESENTATION OF CASE
We present a case of an 81-years-old man admitted in the emergency department with a one week complaints of productive cough, fever, dyspnea and left-side chest pain. The chest X-ray revealed a moderated-volume left-side pleural effusion. The pleural fluid analysis was consistent with an exsudative pleural effusion with high levels of amylase. The thoracoabdominal CT raised the suspicion of a pancreaticopleural fistula, confirmed by ERCP. A pancreatic main duct stenting was performed with good results. The patient was discharged asymptomatic after 18 days of hospitalization.
DISCUSSION
Because of PPF insidious presentation it poses a great number of differential diagnosis, so pleural fluid analysis is of paramount importance with high levels of amylase confirming the diagnosis. MRCP and ERCP may establish the fistulous tract between the pancreatic duct and the pleural cavity, with the latter being also therapeutic.
CONCLUSION
The rarity of this complication related to pancreatitis and the seldomly presence of abdominal pain in contrast with chest symptoms poses a diagnostic challenge.
PubMed: 38761693
DOI: 10.1016/j.ijscr.2024.109755 -
Surgery May 2024Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant...
BACKGROUND
Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy.
METHODS
This single-center retrospective study included 812 open pancreaticoduodenectomies (2012-2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification.
RESULTS
There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12-0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1-20.3, P < .001) was predictive of this complication.
CONCLUSION
Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.
PubMed: 38760227
DOI: 10.1016/j.surg.2024.03.039 -
Clinical Endoscopy May 2024Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a... (Review)
Review
Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.
PubMed: 38756067
DOI: 10.5946/ce.2023.254 -
Journal of Surgical Case Reports May 2024Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective...
Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective in reducing mortality. Venous PPH is rare, and identifying its source can be challenging. We report a case of late venous PPH in the context of a pancreatic fistula following pancreaticoduodenectomy. During surgical exploration, the area of potential bleeding was inaccessible due to major inflammatory adhesions aggravated by the presence of pancreatic fistula and the delay of relaparotomy. No intra-abdominal bleeding was detected on imaging studies or during abdominal exploration; only a massive bleeding through the drain orifice, which required packing, was observed. Percutaneous transhepatic portography was performed to localize and treat the origin of the bleeding. The hemorrhage was successfully treated by endovascular approach. We found no reports in the literature on the use of interventional radiology with venous stenting to treat venous PPH, except in cases of gastrointestinal variceal hemorrhage due to portal occlusion.
PubMed: 38752152
DOI: 10.1093/jscr/rjae256 -
BMC Surgery May 2024Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in...
BACKGROUND
Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center.
METHODS
This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed.
RESULTS
A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups.
CONCLUSION
Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management.
Topics: Humans; Pancreaticoduodenectomy; Male; Female; Retrospective Studies; Laparoscopy; Middle Aged; Postoperative Complications; Aged; Risk Factors; Gastric Emptying; Gastroparesis; Adult
PubMed: 38734631
DOI: 10.1186/s12893-024-02447-7 -
Journal of Clinical Medicine Research Apr 2024Pancreatoduodenectomy (PD) is a very complex and highly challenging operation for surgeons worldwide. It is the surgical procedure of choice for the management of benign...
Pancreatoduodenectomy (PD) is a very complex and highly challenging operation for surgeons worldwide. It is the surgical procedure of choice for the management of benign and malignant diseases of the periampullary region. Although mortality rate following this complicated surgery has fallen to 1-3%, morbidity rate following PD remains high, with almost 30-40% of patients developing at least one complication. Postoperative pancreatic fistula (POPF) is one of the most common complications following PD. Therefore, Pancreatico-enteric anastomosis has been regarded as the "Achilles heel" of the modern, one-stage PD procedure. According to the International Study Group of Pancreatic Surgery (ISGPS), three types of POPF are recognized nowadays: biochemical leak, previously known as grade A POPF, grade B and grade C, with the latter being the most dangerous. Most POPFs, especially of the biochemical leak and grade B heal with non-operative management to recur later and present as an intra-abdominal abscess or pseudocyst, necessitating management by means of interventional radiology, endoscopy or surgery. These types of fistulas are undefined and occasionally intractable. Herein, we present two patients who presented with the aforementioned type of pancreatic fistula following duct occlusion PD. The first patient, a 53-year-old female patient, suffered from intolerance to oral feeding, severe weight loss and recurrent hospital admission, while the second patient, a 72-year-old patient, suffered from recurrent bouts of abdominal sepsis. Their management involved step-up approach, starting with non-operative management, followed by percutaneous drainage and operative treatment in the form of Puestow-like procedure (longitudinal pancreatojejunostomy), as a recourse due to the inadequacy of preceding therapeutic modalities.
PubMed: 38715561
DOI: 10.14740/jocmr5123 -
Surgical Case Reports May 2024Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving...
BACKGROUND
Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions.
CASE PRESENTATION
This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases.
CONCLUSIONS
The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.
PubMed: 38714591
DOI: 10.1186/s40792-024-01914-w -
Journal of Surgical Case Reports May 2024In selected patients with metastatic renal cell carcinoma, metastasectomy can achieve prolonged survival. Herein we report a patient with concomitant pancreatic and...
In selected patients with metastatic renal cell carcinoma, metastasectomy can achieve prolonged survival. Herein we report a patient with concomitant pancreatic and duodenal metastases occurring 12 years after total right nephrectomy for a renal cell carcinoma. The metastases were successfully treated by a pancreas-sparing duodenectomy and distal pancreatectomy. A 66-year-old man was referred to our hospital with a chief complaint of right upper abdominal pain. He had undergone laparoscopic total right nephrectomy for renal cell carcinoma 12 years before. Enhanced computed tomography showed hypervascular tumors in the pancreatic body and the descending duodenum near the papilla of Vater. Histopathological examination of endoscopic ultrasonography-guided fine needle aspiration cytology specimens revealed metastatic clear cell renal cancer. The patient underwent pancreas-sparing duodenectomy and distal pancreatectomy. He developed a pancreatic fistula after surgery that improved with conservative treatment, and has been free of evidence of recurrence up to 20 months postoperatively.
PubMed: 38706478
DOI: 10.1093/jscr/rjae276