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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 -
The Korean Journal of Gastroenterology... Feb 2024Duodenal neuroendocrine tumors (NETs) are subepithelial tumors that are difficult to remove endoscopically, particularly when located just beyond the pylorus. This paper...
Duodenal neuroendocrine tumors (NETs) are subepithelial tumors that are difficult to remove endoscopically, particularly when located just beyond the pylorus. This paper reports a case of a successful endoscopic submucosal dissection (ESD) using open gastric peroral endoscopic myotomy (POEM) for a remnant duodenal NET detected after endoscopic mucosal resection (EMR). A 67-year-old male presented with a 5 mm remnant duodenal NET close to the pylorus after EMR for a duodenal polypoid lesion performed four months earlier. Duodenal ESD was performed under conscious sedation using I-type and IT II knives. The tumor adhered to the fibrotic tissue, and the submucosal cushion was insufficient. Open gastric POEM was performed concurrently during ESD, resulting in the complete resection of the NET. This case suggests that while challenging, open gastric POEM can serve as a valuable technique for endoscopic resection in cases of early gastric cancer or duodenal masses located around the pylorus.
Topics: Male; Humans; Aged; Endoscopic Mucosal Resection; Stomach Neoplasms; Treatment Outcome; Neuroendocrine Tumors; Esophageal Achalasia; Esophageal Sphincter, Lower; Duodenal Neoplasms; Myotomy; Intestinal Neoplasms; Pancreatic Neoplasms
PubMed: 38389462
DOI: 10.4166/kjg.2023.145 -
Journal of Laparoendoscopic & Advanced... Mar 2024To introduce laparoscopic neo-pancreaticogastrostomy (neo-PG) and investigate its application potential in total laparoscopic pancreaticoduodenectomy (TLPD). We... (Clinical Trial)
Clinical Trial
To introduce laparoscopic neo-pancreaticogastrostomy (neo-PG) and investigate its application potential in total laparoscopic pancreaticoduodenectomy (TLPD). We performed a single-center prospective single-arm trial to evaluate the feasibility and safety of neo-PG for its initial application in TLPD. The first 50 patients who were operated by a single surgeon and who underwent TLPD with neo-PG at our institution were recruited. The pre/intra/postoperation data were collected and analyzed. Twenty-nine male patients and 21 female patients from May 2022 to March 2023 were included. The mean operation time was 272.60 ± 47.30 minutes. The median PG time was 16 (15, 23) minutes. Six patients had delayed gastric emptying (DGE), and all underwent standard LPD. None of the patients had Grade B/C postoperative pancreatic fistula (POPF) or postoperative hemorrhage, or underwent reoperation. The median length of post-LPD hospital stay was 6 (6, 8) days. None of the patients died within 90 days after surgery. Nineteen cases were pathologically classified as pancreatic lesion, 6 cases as bile duct lesion, 18 cases as duodenal lesion, and 7 cases as ampullary lesion. The laparoscopic neo-PG is a simple, safe, and feasible pancreatic anastomosis that can be applied in TLPD. Pylorus-preserving LPD may decrease DGE rate. Further studies involving more surgeons are warranted to prove that our new technique may terminate POPF in TLPD.
Topics: Female; Humans; Male; Anastomosis, Surgical; Laparoscopy; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Prospective Studies; Retrospective Studies
PubMed: 38386987
DOI: 10.1089/lap.2023.0360 -
Cureus Feb 2024We present a case of a 43-year-old man with Crohn's disease who presented with epigastric and right upper quadrant abdominal pain, initially suspected to be acute...
We present a case of a 43-year-old man with Crohn's disease who presented with epigastric and right upper quadrant abdominal pain, initially suspected to be acute cholecystitis or a Crohn's flare-up. CT revealed a curvilinear, hyperdense foreign body adjacent to the duodenum, concerning micro-perforation. Endoscopic examination confirmed findings of a 3 cm fish bone lodged in the pylorus. Endoscopic extraction was successful without significant mucosal damage, and the patient recovered well postoperatively. This case highlights the rarity of pyloric perforation secondary to fish bone ingestion and highlights the importance of considering this diagnosis in patients presenting with unexplained acute abdominal pain, as prompt recognition and intervention are essential for favorable outcomes.
PubMed: 38384865
DOI: 10.7759/cureus.54596 -
Asian Journal of Surgery Jun 2024
Topics: Humans; Adolescent; Diaphragm; Male; Female; Pylorus
PubMed: 38383185
DOI: 10.1016/j.asjsur.2024.02.031 -
Neurogastroenterology and Motility May 2024Animal models and human data have suggested macrophage-driven immune dysregulation in diabetic gastroparesis (DG). Translocator protein (TSPO) upregulation has been...
BACKGROUND
Animal models and human data have suggested macrophage-driven immune dysregulation in diabetic gastroparesis (DG). Translocator protein (TSPO) upregulation has been suggested to indicate activated state of macrophages and ER176 is a high affinity third generation TSPO-specific radioligand. The aim of this study was to determine feasibility of dynamic C-ER 176 PET to identify macrophage activation in DG.
METHODS
Twelve patients, all females, were recruited (4 DG, 4 diabetics, and 4 healthy volunteers) for C-ER 176 PET/CT scanning. The standardized uptake value (SUV) in the gastric fundus, body, pylorus, and descending part of the duodenum were compared between three groups using Kruskal-Wallis test to perform the comparisons, and a p-value of 0.05 was considered statistically significant.
KEY RESULTS
Age was comparable among the three groups with a median of 53 years. The uptake was higher in pylorus in diabetics compared to DG and healthy (SUV healthy 4.6 ± 0.2, diabetics 8.4 ± 4.1, DG 5.5 ± 1.0, p = 0.04). The uptake was similar in gastric fundus (9.0 ± 1.6, 13.1 ± 8.3, 7.8 ± 1.9 respectively, p = 0.3), body (7.7 ± 1.9, 13 ± 9.2, 7.8 ± 1.9 respectively, p = 0.8), and duodenum (6.2 ± 2.1, 9.5 ± 6.8, 7.0 ± 1.8 respectively, p = 0.6). No correlation was observed between SUV uptake and either HbA1C or fasting blood glucose.
CONCLUSIONS AND INFERENCES
Female diabetic gastroparesis patients did not demonstrate increased TSPO ligand C-ER 176 uptake in the stomach. Possible explanations include lack of specificity of ligand for specific macrophage phenotypes in DG, sex effect, or small sample size. Further studies investigating non-invasive ways of analyzing immune dysregulation in neurogastrointestinal disorders are warranted.
Topics: Humans; Female; Gastroparesis; Middle Aged; Adult; Macrophage Activation; Positron Emission Tomography Computed Tomography; Positron-Emission Tomography; Aged; Carbon Radioisotopes; Diabetes Complications
PubMed: 38376247
DOI: 10.1111/nmo.14762 -
Veterinary Radiology & Ultrasound : the... May 2024At the pyloroduodenal junction (PDJ), an increase in wall echogenicity is frequently observed. A prospective study was performed to assess the PDJ sonographically in 175...
At the pyloroduodenal junction (PDJ), an increase in wall echogenicity is frequently observed. A prospective study was performed to assess the PDJ sonographically in 175 adults and small dogs (>1 year old, <11.4 kg (25 lb)) over 12 months to evaluate the prevalence of this finding. Additionally, changes in echogenicity were correlated with histology in 14 postmortem specimens. A scoring system of echogenicity change centered on the mucosa and submucosa of the PDJ was implemented; 0: no change, 1: mild, 2: moderate to marked. Other included parameters were age, sex, breed, gastric distention, gastric contents, and reported vomiting at the time of presentation. Hyperechogenicity of the PDJ was highly prevalent (scores 1 and 2: 85.7%). No statistical association between hyperechogenicity of the PDJ and age, sex, gastric distention, gastric contents, or vomiting was identified. Hyperechogenicity of the PDJ is thought to represent an anatomical transition zone, and based on histology, hyperechogenicity of the PDJ may represent a variation in distribution and amount of fibrous connective tissue, glandular number, and glandular dilation within the submucosa and mucosa.
Topics: Animals; Dogs; Female; Male; Prospective Studies; Ultrasonography; Pylorus; Prevalence; Duodenum; Dog Diseases
PubMed: 38372070
DOI: 10.1111/vru.13348