SEVERE COVID-19 IN PATIENT AT EARLY POSTOPERATIVE PERIOD AFTER WHIPPLE’S OPERATION WITH MARGINAL PORTAL VEIN RESECTION

Introduction. Pancreatoduodenectomy (PDR or Whipple’s operation) remains the only effective radical method of surgery for tumors of the pancreatic head, distal common bile duct and Vater’s papilla. The most frequent complications of the early postoperative period are: gastrostasis, pancreatic fistula, postoperative bleeding and pulmonary complications. According to World Health Organization (WHO) and reviews, severe COVID-19 usually occurs in older age patients, and in patients with oncological diseases. Case description. Patient V., 64 years old, due to a tumor of the head of the pancreas with invasion of the distal common bile duct and the development of obstructive jaundice, underwent PDR. Histopathologically, ductal adenocarcinoma of the pancreatic head, G-2, was confirmed. The PDR operation was performed within healthy tissues, which was confirmed by histopathology. On the second day after surgery, patient was admitted to ICU because of respiratory failure, the SARS-CoV-2 antigen test was positive, we suggest that the patient was in the latent period of COVID-19 disease during the surgery. Patient received hormone therapy, anticoagulants in therapeutic doses, O2-therapy. On the 5th day, because of severe ARDS, the patient was intubated, on the 7th day - convalescent plasma transfused (1 dose). On the 9th day, a tracheostomy was applied for airways care and early activation. Respiratory support was provided twelve days. Patient received early activation, exercises, as well as early enteral nutrition. After ICU discharge, patient’s condition was complicated by the gastro-intestinal bleeding, blood transfusion and embolization of the dorsal pancreatic artery were performed. On the day 66th after surgery patient was discharged home in satisfactory condition. Conclusion. General care and early activation of the patient within early tracheostomy, convalescent plasma usage and the well-coordinated work of the surgical and anesthesiological teams allows timely identification and elimination of early postoperative complications after Whipple’s operation with marginal resection of the portal vein.

A Multidisciplinary Approach to the Treatment of COVID-Associated Complications After Pancreatoduodenal Resection (Case Report)

We report a clinical case of treatment of a complicated postoperative course in a patient who underwent pancreatoduodenal resection associated with coronavirus infection. Prevention and treatment of such complications have been suggested.Pancreatoduodenal resection (PDR) is indicated for malignant tumors of the pancreatic head, duodenum or its large papilla, distal common bile duct, as well as in chronic pancreatitis with a predominant lesion of the pancreatic head with severe pain syndrome.The given clinical observation describes an example of treatment of a patient who developed a series of thromboembolic complications in the early stages after PDR performed for a neuroendocrine tumor of the pancreatic head. The oncology disease, extensive surgery such as PDR, and the postoperative period itself are risk factors for the development of various thromboembolic complications. According to the literature, the incidence of thromboembolic complications after PDR is 3–3.3%.The reason for the atypical course of the postoperative period when performing pancreatoduodenal resection in patients with tumor of the pancreas may be conditions that are not directly related to either the pathology of the pancreas or the features of the surgical intervention. When analyzing the patient’s condition, one should take into account the conditions of treatment. In such situations, proper detection of COVID-19 and adequate correction of therapy can fundamentally change the outcome of the disease.

Focal IgG4-related autoimmune pancreatitis with distal choledochal adenocarcinoma: a rare case report

Background Autoimmune pancreatitis (AIP) is a rare disease that manifests as pancreatic involvement in systemic IgG4-related disease (IgG4-RD), a special type of chronic pancreatitis caused by autoimmune abnormalities. The main imaging manifestations of IgG4-related AIP consist of diffuse or localized pancreatic enlargement and irregular pancreatic duct narrowing. The diagnosis of AIP is challenging because it can present with focal lesions, similar to radiologically bile duct cancer or pancreatic cancer. Case presentation A 55-year-old male patient was admitted with painless jaundice and multiple radiographic findings of pancreatic head mass, as well as intrahepatic and extrahepatic bile duct dilatation. Various imaging methods indicated pancreatic cancer. However, the endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) and a laparoscopic pancreatic biopsy suggested an IgG4-related AIP. After one month, magnetic resonance imaging showed that the lesion had slightly grown. Combined with CA19-9 and other indexes, the possibility of malignancy was high and there were still surgical indications. The pathological analysis following a pancreaticoduodenectomy revealed poorly differentiated adenocarcinoma in the distal common bile duct. Conclusion To date, few reports have described pancreatic or extrapancreatic malignancies in AIP patients, and no association between AIP and bile duct adenocarcinoma has been previously confirmed. This case discuss the differentiation between AIP and malignancy, recent research progress, and the correlation between the two diseases, highlights the importance of carefully evaluating patients with AIP to rule out potential tumors, as well as the critical need for follow up treatment.

A case report of spontaneous biliary peritonitis with accessory liver lobe: rare presentation of a rare pathology

Spontaneous intrahepatic bile duct perforation with associated accessory liver lobe is an exceedingly rare condition with very few cases reported in the literature. Here we report a case of 76 years old man presenting with severe pain, abdominal distension since 3 days having jaundice and signs of peritonitis. Having undergone an exploratory laparotomy, 1 liter of bilious peritoneal fluid was seen with a perforation of left intra hepatic bile duct with a presence of an accessory lobe of liver. The gall bladder was contracted with multiple stones. Extrahepatic biliary duct was found normal intraoperatively. A cholecystectomy with resection of the accessory liver lobe was done. Post operatively patient had persistence of jaundice for which a magnetic resonance cholangiopancreatography was done, revealing a distal common bile duct calculus. Patient underwent endoscopic retrograde cholangiopancreatography with stone extraction on post operative day 10 relieving the symptoms. Patient is on regular follow up with no further complications. Awareness of such unusual occurrences is necessary for early diagnosis and instituting the appropriate treatment thereby reducing the mortality.

1500 Chyle Leakage Following Laparoscopic Cholecystectomy: A Problematic Post-Operative Complication

Introduction Symptomatic choleliathiasis is a common surgical issue affecting 10% of the British population, of which laparoscopic cholecystectomy is the gold standard treatment. Asymptomatic chyle leakage post-laparoscopic cholecystectomy is an extremely rare complication. Case Report A 56-year-old man presents with right upper quadrant pain after recurrent episodes of acute cholecystitis. An MRCP showed small stones in the gallbladder and a stone in the distal common bile duct. The management was an urgent in-patient laparoscopic cholecystectomy. At operation, he was found to have significant gallbladder inflammation and a drain was left in-situ. On post-operative day 1, there was a triglyceride rich milky white drain fluid output, which was confirmed as chyle. Method The patient was asymptomatic and systematically well, so a conservative approach was taken. A strict low-fat diet resulted in resolution of the chyle leak, and the drain was removed on post-operative day 4. Follow-up at 8 weeks confirmed full recovery. Conclusions There are four recorded cases of such a phenomenon and is suggested it is caused by iatrogenic injury to the gallbladder fossa which may contain lymphatic vessels. The gold standard investigation is lymphoscintography, although drain fluid analysis and computed tomography imaging are more attainable investigations. Conservative management includes a fat-free diet, total parenteral nutrition and ocreotide whereas surgical management includes identifying the site of leakage and suturing it or applying fibrin glue. Lessons from this unexpected complication include treating the patient, cautiously monitoring the drain and considering surgical intervention if conservative management fails.