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Journal of Surgical Case Reports Mar 2024Cystic tumors account for 15% of pancreatic tumors. Of these, serous microcystic adenomas represent 1-2% of pancreatic exocrine neoplasms. While typically benign, a...
Cystic tumors account for 15% of pancreatic tumors. Of these, serous microcystic adenomas represent 1-2% of pancreatic exocrine neoplasms. While typically benign, a small percentage possess malignant potential. Given imaging improvements, serous cystadenomas are being identified more frequently. A 63-year-old female was admitted with complaints of jaundice and unintentional weight loss. Abdominal computed tomography scan showed a 16 cm obstructive pancreatic mass near the porta hepatis region. Endoscopic ultrasonography and fine needle aspiration biopsy indicated a large pancreatic head cystic mass favoring serous microcystadenoma causing biliary and some pyloric obstruction. Malignant potential could not be ruled out because of size and symptoms. A pylorus-preserving pancreaticoduodenectomy revealed a cystic tumor invading the pancreatic duct and adhering to the duodenum of the pancreatic head. Pathology confirmed a 15 cm benign pancreatic serous cystadenoma. Although most serous cystadenomas are benign, surgical resection was prudent given the size, symptoms, and adjacent organ involvement.
PubMed: 38463732
DOI: 10.1093/jscr/rjae105 -
Annals of Gastroenterological Surgery Mar 2024Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit.
BACKGROUND
Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit.
METHODS
A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus.
RESULTS
Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip ( < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage ( < 0.001).
CONCLUSION
Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.
PubMed: 38455484
DOI: 10.1002/ags3.12754 -
Annals of the Royal College of Surgeons... May 2024Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of...
BACKGROUND
Duodenal injuries are relatively rare but remain a management challenge with a high incidence of postoperative complications. Guidelines from the World Society of Emergency Surgery and American Association for the Surgery of Trauma favour a primary repair for less-complex injuries, but the management of more complex duodenal trauma remains controversial with varying techniques supported, including pyloric exclusion, omental or jejunal patch closure, gastrojejunostomy and pancreatoduodenectomy. We describe the techniques used in one case of complex duodenal trauma.
TECHNIQUE
The duodenum is approached via a standard laparotomy with Kocherisation. Primary repair of the duodenal perforations is performed using a 3/0 polydioxanone suture (PDS), followed by mobilisation of a loop of mid-jejunum against the area of duodenal trauma over the primary repair as a jejunal serosal patch. The antimesenteric jejunal serosal border is sutured to the serosa of the duodenum (serosa only) using a 3/0 PDS. Pyloric exclusion is then performed through an anterior gastrostomy, to control the volume of gastric juice entering the duodenum. The pylorus is sutured closed using an absorbable suture followed by closure of the anterior gastrostomy using a GIA stapling device.
Topics: Humans; Male; Duodenum; Intestinal Perforation; Jejunum; Pylorus; Serous Membrane; Suture Techniques; Middle Aged
PubMed: 38445581
DOI: 10.1308/rcsann.2023.0074 -
Frontiers in Surgery 2024Periampullary neoplasm is rare in pediatric patients and has constituted a strict indication for pancreatoduodenectomy (PD), which is a procedure sporadically reported...
Periampullary neoplasm is rare in pediatric patients and has constituted a strict indication for pancreatoduodenectomy (PD), which is a procedure sporadically reported in the literature among children. Robotic PD has been routinely performed for periampullary neoplasm in periampullary neoplasm, but only a few cases in pediatric patients have been reported. Here, we report the case of a 3-year-old patient with periampullary rhabdomyosarcoma treated with robotic pylorus-preserving PD and share our experience with this procedure in pediatric patients. A 3-year-old patient presented with obstructive jaundice and a mass in the pancreatic head revealed by imaging. A laparoscopic biopsy was performed. Jaundice progressed with abdominal pain and elevated alpha-amylase leading to urgent robotic exploration in which a periampullary neoplasm was revealed and pathologically diagnosed as rhabdomyosarcoma by frozen section examination. After pylorus-preserving PD, we performed a conventional jejunal loop following a child reconstruction, including an end-to-end pancreaticojejunostomy, followed by end-to-side hepaticojejunostomy and duodenojejunostomy. Delayed gastric emptying (DGE) presented with increasing drain from the nasogastric tube (NGT) a week after the surgery and improved spontaneously within 10 days. In a 13-month follow-up until the present, our case patient recovered well without potentially fatal complications, such as pancreatic fistula. Robotic PD in pediatric patients was safe and effective without intra- or postoperative complications.
PubMed: 38440415
DOI: 10.3389/fsurg.2024.1284257 -
Cancer Diagnosis & Prognosis 2024Given that gastric small cell neuroendocrine carcinoma (SCNEC) is notably more aggressive than conventional adenocarcinoma, and a platinum-based regimen aligned with the...
BACKGROUND/AIM
Given that gastric small cell neuroendocrine carcinoma (SCNEC) is notably more aggressive than conventional adenocarcinoma, and a platinum-based regimen aligned with the treatment for pulmonary SCNEC is advocated when chemotherapy is needed, ensuring an accurate pathological diagnosis is paramount.
CASE REPORT
A 63-year-old man, examined for melena, underwent gastroscopy which revealed a total circumferential Borrmann type 3 lesion extending from the pylorus to the antrum of the stomach. He underwent a distal gastrectomy with D2 lymphadenectomy. The microscopic examination revealed SCNEC with a minor adenocarcinoma component. Immunohistochemically, the SCNEC was diffusely positive for synaptophysin, CD56, and INSM1, very focally positive for chromogranin A, and negative for leukocyte common antigen, CD3, and CD20. A significant observation in this case was the complete negativity for epithelial markers including keratin (CK7, CK8, CK20, CAM5.2, and AE1/AE3) and epithelial membrane antigen.
CONCLUSION
Diffuse positivity for neuroendocrine markers, negativity for other lineage markers, and a transition from the adenocarcinoma component, if present, serve as significant diagnostic clues for gastric SCNEC with loss of epithelial markers expression. SCNEC should not be excluded solely based on the negative result for epithelial markers.
PubMed: 38434925
DOI: 10.21873/cdp.10306 -
Endoscopy Dec 2024
Topics: Humans; Stomach Neoplasms; Endoscopic Mucosal Resection; Pylorus; Gastroscopy; Endoscopes; Gastric Mucosa; Treatment Outcome
PubMed: 38428911
DOI: 10.1055/a-2264-1164 -
Updates in Surgery Feb 2024Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological...
Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological outcomes. Among these variations, a common hepatic artery arising from the superior mesenteric artery (SMA) occurs in about 3% of cases. An exceptionally rare variation is the intrapancreatic common hepatic artery (IPCHA). Preserving or reconstructing the IPCHA is vital during PD to prevent liver and biliary necrosis. Particularly for cases of pancreatic cancer with high rates of intrapancreatic perineural spread, preserving IPCHA without compromising radicality presents challenges. We present a detailed report of the technique used for PD in the presence of IPCHA. Surgical technique details include a pylorus-preserving PD with the Cattell-Braasch maneuver, an artery-first approach, and meticulous dissection using "cold" scissors. We emphasize the importance of strategic surgical planning based on high-quality imaging studies, underscoring the need for pancreatic surgeons to be proficient in managing variations in visceral vessels. In conclusion, this case underscores the significance of navigating rare arterial variations in liver supply during PD, highlighting the necessity for meticulous surgical planning and execution.
PubMed: 38418694
DOI: 10.1007/s13304-024-01784-9 -
Pediatric Radiology May 2024Ultrasound is the modality of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). The evolution of high-frequency transducers in ultrasound has led to...
BACKGROUND
Ultrasound is the modality of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). The evolution of high-frequency transducers in ultrasound has led to inconsistent ways of measuring the pylorus.
OBJECTIVE
To standardize the measurements and evaluate the appearance of the normal and hypertrophied pylorus with high-frequency transducers.
MATERIALS AND METHODS
We retrospectively analyzed abdominal ultrasounds of infants with suspected HPS from January 2019-December 2020. We classified the layers of the pylorus while assessing the stratified appearance. Two pediatric radiologists measured the muscle thickness of the pylorus independently by two methods for interrater agreement. Measurement (a) includes the muscularis propria and muscularis mucosa. Measurement (b) includes only the muscularis propria. We also evaluated the echogenicity of the muscularis propria. The interrater agreement, mean, range of the muscle thickness, and the diagnostic accuracy of the two sets of measurements were calculated.
RESULTS
We included 300 infants (114 F:186 M), 59 with HPS and 241 normal cases. There was a strong agreement between the readers assessed in the first 100 cases, and ICC was 0.99 (95% CI, 0.98-0.99). Measurement (a), median thickness is 2.4 mm in normal cases and 4.8 mm in HPS. Measurement (b), median thickness is 1.4 mm in normal cases and 4.0 mm in HPS. Measurement (a) has an accuracy of 89.7% (95% CI, 85.7-92.8%) with 98.3% sensitivity and 87.6% specificity. Measurement (b) has an accuracy of 98.0% (95% CI, 95.7-99.3%) with 89.8% sensitivity and 100.0% specificity. The pylorus stratification is preserved in all normal cases and 31/59 (52.5%) cases of HPS. There was complete/partial loss of stratification in 28/59 (47.5%) cases of HPS. In all HPS cases, the muscularis propria was echogenic.
CONCLUSION
Measuring the muscularis propria solely has a better diagnostic accuracy, decreasing the overlap of negative and positive cases. The loss of pyloric wall stratification and echogenic muscularis propria is only seen in HPS.
Topics: Humans; Retrospective Studies; Male; Female; Ultrasonography; Pylorus; Infant; Pyloric Stenosis, Hypertrophic; Transducers; Infant, Newborn; Sensitivity and Specificity
PubMed: 38418631
DOI: 10.1007/s00247-024-05881-0 -
Medical Sciences (Basel, Switzerland) Feb 2024Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum,... (Review)
Review
Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.
Topics: Humans; Gastroenterostomy; Endosonography; Gastric Outlet Obstruction; Pylorus; Stents; Constriction, Pathologic
PubMed: 38390859
DOI: 10.3390/medsci12010009 -
CRSLS : MIS Case Reports From SLS 2024Performing endoscopic retrograde cholangiopancreatography (ERCP) in duodenal switch (DS) patients is challenging given their surgically altered anatomy. There have been...
INTRODUCTION
Performing endoscopic retrograde cholangiopancreatography (ERCP) in duodenal switch (DS) patients is challenging given their surgically altered anatomy. There have been very few reported cases of trans enteric rendezvous ERCP to relieve biliary obstruction in DS patients. More specifically, there has not been any reported cases of this procedure being performed in loop DS, also known as SADI (single anastomosis duodeno-ileostomy) or SIPS (stomach intestinal pylorus sparing procedure).
CASE DESCRIPTION
This case reports describes a 50-year-old male with prior loop DS who presented with gallstone pancreatitis. He underwent a laparoscopic cholecystectomy with positive intraoperative cholangiogram requiring the need for trans enteric rendezvous ERCP.
DISCUSSION
Although never reported, trans enteric rendezvous ERCP is a feasible approach in relieving biliary obstruction in patients with loop DS anatomy.
Topics: Male; Humans; Middle Aged; Cholangiopancreatography, Endoscopic Retrograde; Intestines; Digestive System Surgical Procedures; Anastomosis, Surgical; Cholestasis
PubMed: 38389993
DOI: 10.4293/CRSLS.2023.00053