Bifid Pancreatic Tail: an Anatomical Case Series and their Classification

Anomalies and variants of development of the pancreas are relatively frequent. Bifid pancreatic tail is a rare anatomic variation with only a few cases reported in the literature. The present case series were encountered during dissection of 50 anatomical specimens of the pancreas, spleen, and duodenum. We observed four unusual cases (8%) of bifid pancreatic tail. One case was of a vertically oriented bifid pancreas tail (2%), in another case, the tails here horizontally oriented (2%) and in two cases the bifid tails were horizontally oriented but unequal (4%). The bifid tails had an arterial supply that penetrated the glands between the tails and two out of four were also supplied by the superior horizontal pancreatic artery of Popova. The ductal system usually bifurcated at the level of the tails, but a case of trifurcation was also encountered. The current cases should be taken into account in hepato-pancreato-biliary surgery to avoid misdiagnosis and to comprehensively assess the patient preoperatively.

Infections of Biliary Tract

Biliary tract infections include cholangitis and cholecystitis. They are associated with high morbidity and mortality in elderly patients with comorbid disease. The most common infecting organisms are Enterobacteriaceae ascending from the gastrointestinal tract, Gram-positive pathogens like Enterococci spp.; the infections are rarely caused by fungi, viruses, and parasites. The prime reason for biliary tract infections is the ascending infection due to the reflux of duodenal contents and also the blood-borne infection or infection spreading through the portal-venous channels. The other predisposing conditions causing biliary tract infections include critical illnesses such as trauma, burns, sepsis, HIV infection, immunosuppression, diabetes, non-biliary surgery, and childbirth. The infection is reduced by β-lactam antibiotics or their derivatives, cephalosporins, carbapenems, fluoroquinolones, etc. Empiric treatment with piperacillin/tazobactam or a cephalosporin with or without metronidazole is recommended for moderate and severe acute cholecystitis irrespective of whether there is growth by culture. Patients with severe cholecystitis are unfortunately difficult to identify properly, both clinically and radiologically, because clinical symptoms are unexpected, and imaging investigations are frequently ambiguous. However, there are significant differences in morbidity and death rates between individuals with mild cholecystitis and those with severe cholecystitis. Preventing related consequences requires early identification and effective therapy of individuals at risk of severe cholecystitis.

PREVENTION OF INCISIONAL HERNIA AFTER OPEN HEPATO-PANCREATO-BILIARY SURGERY: A SYSTEMATIC REVIEW

Introduction Most hepato-pancreato-biliary (HPB) procedures are still performed through open approach. Incisional hernia (IH) is one of the most common complications after open surgery. To date, published data on IH after HPB surgery are scarce, therefore the aim of this study was to assess the current evidence regarding incidence, risk factors, and prevention. Methods Medline/PubMed (1946-2020), EMBASE (1947-2020), and the Cochrane library (1995-2020)) were searched for studies on IH in open HPB surgery. Animal studies, editorials, letters, reviews, comments, short case series and liver transplant, laparoscopic or robotic procedures were excluded. The protocol was registered with PROSPERO (CRD42020163296). Results A total of 5 079 articles were retrieved. 8 studies were finally included for the analysis. The incidence of IH after HPB surgery ranges from 7.7% to 38.8%. The identified risk factors were body mass index, surgical site infection, ascites, Mercedes or reversed T incisions and previous IH. Prophylactic mesh might be safe and effective. Conclusions IH after open HPB surgery is still an important matter. Some of the risk factors are specific for the HPB operations and the incision type should be carefully considered. Randomised controlled trials are required to confirm the role of prophylactic mesh after HPB operations.

P-BN26 The effect of cholecystectomy on unplanned admissions following endoscopic sphincterotomy and bile duct stone removal

Background Choledocholithiasis is common, with patients usually treated with ERCP and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focussed on recurrent CBD stones, negating the risks of cholecystectomy. Methods Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James’s University Hospital January 2015 - December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Results 844 patients received ERCP and CBD clearance with 3.9 years follow up. 209 patients underwent cholecystectomy with 15% requiring complex surgery. 373 patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. Conclusions The majority of patients do not require readmission following ERCP for CBD stones and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but difficult biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Liver, pancreatic, and biliary surgery

This chapter outlines the assessment of a patient who presents with jaundice. The management of the common benign conditions affecting the liver, pancreas and biliary system, such as gallstones, common bile duct stones, acute and chronic pancreatitis, benign liver lesions, liver cirrhosis and portal hypertension, are detailed. It also describes the management of the relevant malignancies; pancreatic cancer, hepatocellular cancer, cholangiocarcinoma, gallbladder cancer and colorectal liver metastases.

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 (90Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following 90Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.