Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

P-EGS16 Lemmel Syndrome due to Duodenal Diverticulitis, an Infrequent Cause of Biliary Obstruction

Background Lemmel syndrome, first described in 1934, is the presence of biliary obstruction as a consequence of duodenal diverticula. The precise aetiology remains uncertain. Multiple causative theories have been proposed. These include mechanical biliopancreatic duct occlusion, functional disruption of the sphincter of Oddi and alteration of the course of the distal biliary and pancreatic ducts. We present a case of biliary obstruction caused by diverticulitis of a solitary duodenal diverticulum. Methods A 71-year-old woman with no co-morbidities presented with early satiety, cachexia and upper abdominal pain. An epigastric mass was palpable, alkaline phosphatase was 247 iu/L, alanine transaminase 124iu/L, bilirubin 4umol/L and C-reactive protein 68mg/L. Computed tomography (CT) of the abdomen and pelvis revealed obstructed biliary tree with D2 duodenal diverticulitis. Magnetic resonance cholangiopancreatography (MRCP) displayed a causative enterolith. Treatment with antibiotics was initiated and the patient commenced on liquid diet. Liver function tests and inflammatory markers normalised. After a seven day admission patient was discharged and oral intake normalised. Interval MRCP revealed resolution of obstruction and inflammation. Results Duodenal diverticula occur in 1-20% of individuals. Complications are symptoms are uncommon. Diverticulitis is a rare complication. Malignancy and cholelithiasis should be excluded in diagnostic workup. The mainstay of therapy for duodenal diverticulitis is conservative. CT and MRCP are effective diagnostic tools. Diverticulectomy carries substantial risk of morbidity and mortality. Endoscopic sphincterotomy or lavage have a role in relief of biliary obstruction when present. Comparative prospective studies of management do not exist and retrospective enquiry is sparse. Management is thereby best determined clinically on a case by case basis. Surgery is reserved for failed conservative and medical therapy. Conclusions Duodenal diverticulitis should be considered in patients with unexplained upper abdominal pain and elevated inflammatory markers. In combination with obstructive jaundice, suspicions should be raised for acute inflammation causing obstruction to the biliary tree. Cross sectional imaging is useful in determining the diagnosis. Antibiotics and conservative therapy are prudent first line management in the absence of perforation. Where these measures are inadequate endoscopic and operative strategies may be employed but have no robust evidence basis.

Percutaneous Transhepatic Biodegradable Biliary Stent Placement for Benign Biliary Strictures

This article aimed to assess the safety and effectiveness of biodegradable stents in the management of benign biliary strictures. This is a retrospective observational study that included all adult patients who had biodegradable stent placement for a benign cause of biliary stricture between July 2016 and August 2019. Nineteen patients were included. Seventeen patients had liver transplant. One patient had hepaticojejunostomy due to primary sclerosing cholangitis and one patient had iatrogenic left main bile duct occlusion. Stents were successfully deployed in all 19 patients (technical success: 100%). Patency rate was 90% (17/19) at 6 months and 80% (12/15) at 12 months. Seven patients in the study had stricture recurrence and needed reintervention with mean time to reintervention of 418 days (range: 8–1,155 days). There was one major complication due to cholangitis and sepsis, which required a treatment course with piperacillin/tazobactam for 10 days. No procedure-related pancreatitis or deaths occurred. Biodegradable stents are a safe and effective treatment option for benign biliary strictures and can achieve long-term patency without the need for reinterventions.

Robotic Subtotal Cholecystectomy in a Geriatric Acute Care Surgery Patient with Super Obesity

Introduction. Unique challenges exist with conventional laparoscopic operations in patients with super obesity ( BMI > 50 ). Limited literature is available regarding use of the robotic platform to treat patients with super obesity or acute care surgery patients. This case describes an interval robotic subtotal cholecystectomy in an elderly patient with super obesity and multiple comorbidities. Case Description. A 74-year-old male with a BMI of 59.9 developed acute cholecystitis. He was deemed excessively high risk for operative intervention due to concurrent comorbid conditions and underwent percutaneous cholecystostomy. After a few months, a cholangiogram demonstrated persistent cystic duct occlusion. The patient expressed interest in tube removal and elective interval cholecystectomy. After preoperative risk stratification and optimization, he underwent a robotic subtotal cholecystectomy with near infrared fluorescence cholangiography. The patient was discharged on postoperative day one and recovered without complications. Discussion. Obesity is a risk factor for acute cholecystitis, which is most commonly treated with conventional laparoscopy (CL). CL is technically restraining and difficult to perform in patients with super obesity. The body habitus of patients with super obesity can impair proper instrumentation and increase perioperative morbidity. In this case, robotic assisted cholecystectomy console improved surgeon ergonomics and provided support for proper instrumentation. Robotic, minimally invasive cholecystectomy approaches may reduce perioperative morbidity in patients with super obesity. Further studies are necessary to address the role of robotic surgery in acute care surgery patients with super obesity.

A Comparative Study of Dacryocystorhinostomy with or without Stent in a Tertiary Teaching Hospital of Telangana

BACKGROUND Epiphora is a common annoying symptom, embarrassing the patient both socially and functionally and may even endanger the eye. Chronic Dacryocystitis is the most common cause of epiphora which arises from nasolacrimal duct occlusion. Dacryocystorhinostomy (DCR) is the procedure of choice in the management of Dacryocystitis. We wanted to study the final outcome following endonasal DCR for chronic dacryocystitis with or without using silicon stent, evaluate the causes of persistence of epiphora in patients with or without the use of lacrimal stents and identify the methods of overcoming them postoperatively. METHODS A case control study to compare the results of Endonasal DCR with and without stent was conducted among 96 patients of both genders aged above 20 years with symptoms and signs suggestive of nasolacrimal duct blockage. All the cases and controls were randomly selected and included as group A and group B. RESULTS 96 patients were included in this study and they were divided into two groups (Group A and Group B) with 48 patients in each group. More than 75 % of the patients were between 31 and 60 years of age with a mean age of 44.36 ± 3.15 years. In Group B, 72.91 % of the cases were between 31 and 60 years of age with a mean age of 45.50 ± 4.10 years. There was no statistically significant difference in both groups. In group A (DCR with stent) success rate or relief of symptoms was 96 % whereas in group B (DCR without stent) success rate or symptomatic relief was 80 %. CONCLUSIONS Endoscopic endonasal DCR with stent is a safe and minimally invasive procedure and is an effective treatment for patients who have failed primary endoscopic DCR without stent and also in cases of mucocele and pyocele of the sac. KEYWORDS Chronic Dacryocystitis, Dacryocysto-Rhinostomy, Nasolacrimal Duct and Endoscopic Dacryocysto-Rhinostomy

Case report: hepatobronchial lymphatic communications in single ventricle patients as a pathophysiological mechanism of plastic bronchitis: diagnosis and treatment

Background Plastic bronchitis is a rare but devastating complication in single ventricle patients after Fontan completion. Recent advances in dynamic contrast-enhanced magnetic resonance lymphangiogram demonstrate the typical pathophysiological mechanism of the thoracic duct leaking lymphatic fluid towards the bronchi resulting in intraluminal casts. This has been termed abnormal pulmonary lymphatic perfusion and has been successfully treated in 94% of patients with thoracic duct occlusion. However, in some cases, this aberrant flow is not identified and therefore no intervention is available. This case report identifies a newly discovered origin of abnormal lymphatic flow from the liver to the bronchi and the treatment of these patients. Case summary We report two cases of plastic bronchitis in single ventricle patients with no identified abnormal lymphatic pulmonary perfusion from the thoracic duct. Both patients underwent liver lymphangiogram and demonstrated aberrant flow from the hepatic lymphatic ducts to the bronchi. These were successfully occluded, and plastic bronchitis symptoms resolved in both cases. Discussion The recent discovery of the abnormal pulmonary lymphatic perfusion from the thoracic duct to the bronchi has allowed successful treatment of 94% of single ventricle patients with plastic bronchitis. The discovery of hepatobronchial lymphatic perfusion reveals an occult aetiology of plastic bronchitis and a second target for embolization and successful treatment.

Pancreatic Duct Occlusion: A Safe and Valid Alternative to Duct Anastomosis After Pancreaticoduodenectomy in a Low Volume Centre

Background: Pancreaticoduodenectomy is the only possible choice of treatment for peri-ampoullar neoplasms. Morbidity in pancreatic surgery is mainly related to the development of a postoperative pancreatic fistula (POPF). According to International Study Group on Pancreatic Fistula it is possible to grade POPF based on clinical variables. Three main different surgical strategies have been proposed to deal with the pancreatic stump following pancreaticoduodenectomy: pancreatojejunostomy, pancreatogastrostomy and pancreatic duct occlusion, but none of them has been clearly demonstrated to be superior to the others. The aim of our study is to evaluate the feasibility of duct occlusion and its correlations with postoperative pancreatic fistula, “brittle diabetes” and overall survival in a low volume centre. We decided to review our previous experience in the light of the recent Covid pandemic where, in our country, it has been forced in many regions to displace treatment of oncological patients in low volume hospitals with limited experienceMethods: We retrospectively reviewed 56 consecutive patients, from a prospective maintained database, who underwent Whipple’s procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit with a low volume of pancreatic resections. The mean follow-up was 24.5 months. Results: The overall incidence of postoperative pancreatic fistula was 66.6%: 15 patients had a Grade A (31.25%), 13 a Grade B fistula (27.03%), and 4 (8.3%) suffered from a life-threatening Grade C fistula. At the last follow-up, 24 of the 28 patients who were alive (85.6%) habitually used substitutive pancreatic enzyme. Conclusion: Duct occlusion can be a safe alternative to pancreatic anastomosis especially in low volume centres and for those patients (age >75 years, obese, hard pancreatic texture, small pancreatic duct) at higher risk of clinically relevant POPF.Trial registration: 'retrospectively registered'