Cavitojejunostomy for post-traumatic disconnected pancreatic duct syndrome presenting as persistent external pancreatic fistula: A case report

Post-traumatic disconnected pancreatic duct syndrome (DPDS) can present as persistent external pancreatic fistula following percutaneous drainage (PCD) of pancreatic collection. Management of these cases can be difficult and involves a multidisciplinary approach. Here, we present a case of a 16-year-old boy who presented with persisted pancreatic fistula following initial management including PCD of peripancreatic collection following polytrauma 3 months prior. Magnetic resonance imaging showed a disconnected pancreatic duct. Intraoperatively, there was a disconnected and viable distal pancreas with a defect cavity measuring 2 × 2 cm at the neck of the pancreas. The wall of the cavity was anastomosed with a Roux limb of the jejunum (cavitojejunostomy). Post-operative recovery was uneventful and the patient remains asymptomatic at 2 months of follow-up. Cavitojejunostomy is a feasible and safe surgical option in DPDS with a well-formed cavity. This avoids dissection in difficult anatomical planes and preserves pancreatic parenchyma.

En bloc resection in giant bilobed splenic artery aneurysm

Giant splenic artery aneurysms are rare and associated with high morbidity and mortality. Early detection is the key to decreasing morbidity and mortality. We present a giant splenic artery aneurysm which was managed by en bloc resection of the spleen, distal pancreas.

Pancreatic Neuroendocrine Tumor with Benign Serous Cystadenoma: A Rare Entity

Mixed serous-neuroendocrine neoplasm constitutes pancreatic serous cystic neoplasms and pancreatic neuroendocrine tumor, two tumor components with different underlying pathologies. The differentiation of these tumors is important as the management and prognosis depend on the pancreatic neuroendocrine tumor component. We report a case of mixed serous-neuroendocrine neoplasm in a 47-year-old female who presented with epigastric pain abdomen for two years. Imaging studies, tumor markers, thorough systemic evaluation, surgical resection, histopathological examination, and timely follow-up constituted our management approach. A 4 cm × 4 cm mass in the distal pancreas with multiple cysts in the pancreatic parenchyma containing serous fluid on distal pancreatectomy and splenectomy was found. The histopathological examination revealed combined benign serous cystadenoma and neuroendocrine tumor. She did not have any recurrence or metastasis by four years of follow-up.

Automated Detection of Pancreatic Cystic Lesions on CT Using Deep Learning

Pancreatic cystic lesions (PCL) are a frequent and underreported incidental finding on CT scans and can transform into neoplasms with devastating consequences. We developed and evaluated an algorithm based on a two-step nnU-Net architecture for automated detection of PCL on CTs. A total of 543 cysts on 221 abdominal CTs were manually segmented in 3D by a radiology resident in consensus with a board-certified radiologist specialized in abdominal radiology. This information was used to train a two-step nnU-Net for detection with the performance assessed depending on lesions’ volume and location in comparison to three human readers of varying experience. Mean sensitivity was 78.8 ± 0.1%. The sensitivity was highest for large lesions with 87.8% for cysts ≥220 mm3 and for lesions in the distal pancreas with up to 96.2%. The number of false-positive detections for cysts ≥220 mm3 was 0.1 per case. The algorithm’s performance was comparable to human readers. To conclude, automated detection of PCL on CTs is feasible. The proposed model could serve radiologists as a second reading tool. All imaging data and code used in this study are freely available online.

Laparoscopic radical antegrade modular pancreatosplenectomy: preliminary experience with 10 cases

Background The radical antegrade modular pancreatosplenectomy (RAMPS) which is a reasonable surgical approach for left-sided pancreatic cancer is emphasis on the complete resection of regional lymph nodes and tumor-free margin resection. Laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) has been rarely performed, with only 49 cases indexed on PubMed. In this study, we present our experience of LRAMPS. Methods From December 2018 to February 2020, 10 patients underwent LRAMPS for pancreatic cancer at our department. The data of the patient demographics, intraoperative variables, postoperative hospital stay, morbidity, mortality, pathologic findings and follow-up were collected. Results LRAMPS was performed successfully in all the patients. The median operative time was 235 min (range 212–270 min), with an EBL of 120 ml (range 100–200 ml). Postoperative complications occurred in 5 (50.0%) patients. Three patients developed a grade B pancreatic fistula. There was no postoperative 30-day mortality and reoperation. The median postoperative hospital stay was 14 days (range 9–24 days).The median count of retrieved lymph nodes was 15 (range 13–21), and four patients (40%) had malignant-positive lymph nodes. All cases achieved a negative tangential margin and R0 resection. Median follow-up time was 11 months (range 3–14 m). Two patients developed disease recurrence (pancreatic bed recurrence and liver metastasis) 9 months, 10 months after surgery, respectively. Others survived without tumor recurrence or metastasis. Conclusions LRAMPS is technically safe and feasible procedure in well-selected patients with pancreatic cancer in the distal pancreas. The oncologically outcomes need to be further validated based on additional large-volume studies.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy: Preliminary Experience with 10 Cases

BackgroundThe radical antegrade modular pancreatosplenectomy (RAMPS) which is a reasonable surgical approach for left-sided pancreatic cancer is emphasis on the complete resection of regional lymph nodes and tumor-free margin resection. Laparoscopic radical antegrade modular pancreatosplenectomy(LRAMPS) has been rarely performed, with only 49 cases indexed on PubMed. In this study, we present our experience of LRAMPS.Methods: From December 2018 to February 2020, 10 patients underwent LRAMPS for pancreatic cancer at our department. The data of the patient demographics, intraoperative variables , postoperative hospital stay, morbidity, mortality, pathologic findings and follow-up were collected.Results：LRAMPS was performed successfully in all the patients. The median operative time was 235 minutes (range, 212-270min), with an EBL of 120ml(range,100-200ml) . Postoperative complications occurred in 5 (50.0%) patients. Three patients developed a grade B pancreatic fistula. There was no postoperative 30-day mortality and reoperation. The median postoperative hospital stay was 14 days(range,9- 24d).The median count of retrieved lymph nodes was 15 (range, 13–21), and four patients (40%) had malignant-positive lymph nodes. All cases achieved a negative tangential margin and R0 resection.Median follow-up time was 11 months (range, 3–14m). Two patients developed disease recurrence(pancreatic bed recurrence and liver metastasis) 9 months,10 months after surgery,respectively. Others survived without tumor recurrence or metastasis．ConclusionsLRAMPS is technically safe and feasible procedure in well-selected patients with pancreatic cancer in the distal pancreas. The oncologically outcomes need to be further validated based on additional large-volume studies.

Selection of the optimal type of the stapler cassette for distal pancreas resection

Aim of study. Investigation of risk factors in development of postoperative pancreatic fi stula (POPF) in patients aft er distal pancreatectomy (DP) involving application of a cutting stapler device (CS) as well as determination of the criteria for selection of the optimal cassette type for such devices making it possible to reduce the POPF development frequency. Material and methods. A two-centre retrospective/prospective controlled study was performed. A total of 46 patients (19 (41.3 %) male and 27 (58.7 %) female) were enrolled. All patients included in the study underwent DP surgery using CS for excision of the pancreas with closure of its stump. In all cases, measurement of the pancreas thickness in the resection area based on the data of preoperative computed tomography and calculation of the difference between the pancreatic parenchymal thickness in the resection area and the staple closure height (SCH). Th e patients were distributed between two groups: 1) without POPF of with biochemical leakage (BL); 2) with clinically relevant POPF (CR-POPF). Results. CR-POPF developed in 15 (32.6 %) cases (type-B POPF: 14 (93.3 %) cases, type-С: 1 (6.7 %) case). Statistically signifi cant diff erence in mean pancreatic parenchymal thickness in the resection area as well as mean SCH between the group without POPF or with BL and the group with CR-POPF (15.4±4.3mm versus 12.3±3.5mm, р=0.01 and 12.8±2.3mm versus 16.4±3.1mm, р<0.01, respectively). Th e frequency of CR-POPF development was reliably lower at the SCH varying from 8 to 14mm (9.5 %) as compared to cases with SCH below 8mm (55.6 %, p<0.01) and above 14mm (50.0 %, p<0.01). Conclusion. Upon analysis of risk factors in POPF development aft er DP, it has been established that a greater pancreatic parenchymal thickness in the resection area as well as SCH are statistically significant risk factors for this complication. Th e optimal SCH making it possible to achieve the minimal frequency of POPF aft er pancreatic stump closure using a CS is within the range of 8-14mm.