P-P54 Interpreting trends in post-operative drain fluid amylase according to type of anastomosis used to form a pancreaticojejunostomy

Background The formation of the pancreaticojejunostomy during pancreaticoduodenectomy is the most technically challenging aspect of the procedure, with its failure increasing rates of both morbidity and mortality significantly. Early identification and management of a clinically relevant post-operative pancreatic fistula (CR-POPF) can be critical in reducing the threat of potentially avoidable harm to the patient. The most used indicator for a CR-POPF is the level of drain fluid amylase. There are many different techniques for forming the anastomosis, with considerable analysis but no consensus on superiority. We aimed to look at our centres experience using different techniques and the trends we observed in drain amylases and clinical outcomes. Methods A prospective database of all patients in a single UK centre undergoing pancreatic or duodenal resection has been maintained. This includes patient demographics, diagnosis pre and post operatively, operative details and duration, complications, and outcomes. All patients undergoing a pancreaticoduodenectomy between 1st January 2020 and 31st July 2021 were identified and their data retrospectively analysed. Results Thirty-three patients underwent a pancreaticoduodenectomy during the study period. The pancreatojejunostomy was formed using a duct-to-mucosa anastomosis in twenty-eight patients and using a dunking technique in five patients. The mean of the highest drain fluid amylase on post-operative day one for the patients with a dunking anastomosis was 14804.8 (range 3643-43686), on day three 2376.12 (range 167-8008.6) and of the three patients whose drains were in situ at day 5 it was 522.2 (range 31 to 983. An 83.9% reduction in mean drain amylases was observed between Day One and Day Three, followed by a further 78% reduction between day 3 and day. One patient (20%) had a CR-POPF with a grade B fistula, two others had a biochemical leak. The mean Day One drain amylases for patients with a duct-to-mucosa anastomosis was 71% lower at 4274.5 (range 15.4 to 41755). However this increased by 11.5% by Day Three to 4766.4 (range 5 to 46300) before falling by 64.7% to 1681.9 (range 5 to 13015) on Day Five. Eight patients (28.6%) had a CR-POPF – 3 grade B and 5 grade C fistula - and three patients had a biochemical leak. Conclusions In our centre’s experience, the type of anastomosis used to perform the pancreatic reconstruction post pancreaticoduodenostomy significantly impacts the post-operative trend in drain fluid amylase. This is important for clinicians to appreciate in order to avoid premature suspicion of a CR-POPF and prevent potentially unnecessary intervention.

A Case Report of a Bleeding Duodenal Gastro-Intestinal Stromal Tumor and its Emergent Management

A gastrointestinal stromal tumor (GIST) arising in the duodenum is a rare subtype of mesenchymal tumor. GISTs have a reported incidence of 11.9–19.6 per million population and duodenal GISTs make up just 5% of these tumors. Common presentation of duodenal GISTs is through an upper gastrointestinal bleed, of which, they are responsible for less than 1% of all gastrointestinal bleeding. In an elective setting, surgical management remains the mainstay of treatment. In this Case Report, the emergent management of a localized duodenal resection was performed by an acute care surgeon, in an unstable patient. The risk factors for malignancy include tumor size and a high mitotic cell index. Tumor recurrence is determined by tumor size, tumor rupture, high mitotic cell index, a non-gastric location and gastrointestinal bleeding.

Gastrointestinal Intramural Pancreatic Pseudocysts in a Dog: A Case Report and Human Literature Review

ABSTRACT A 9.5 yr old Yorkshire terrier presented with chronic intermittent vomiting and lethargy of 1.5 yr duration that progressed to generalized weakness. Insulin:glucose ratio was consistent with an insulinoma. Triple-phase computed tomography revealed a mid-body pancreatic nodule. The mid-body pancreatic nodule was enucleated; histopathology was consistent with an insulinoma. Two weeks after the operation, the dog presented for anorexia and diarrhea. Abdominal ultrasound revealed a thick-walled cystic lesion along the dorsal stomach wall. An intramural gastric pseudocyst was diagnosed via exploratory laparotomy and intraoperative gastroscopy. Comparison of amylase and lipase levels of the cystic fluid with that of concurrent blood serum samples confirmed the lesion was of pancreatic pseudocyst origin. The gastric pseudocyst was omentalized. Two weeks after the operation, the dog re-presented for anorexia, regurgitation, and diarrhea. An intramural duodenal pseudocyst was identified and treated with a duodenal resection and anastomosis. The dog has remained asymptomatic and recurrence free based on serial abdominal ultrasounds 22 mo following insulinoma removal. To our knowledge, this phenomenon of pancreatic pseudocysts forming in organs other than the pancreas has not been reported in dogs. This case report and comprehensive human literature review purpose is to raise awareness of this disease process in dogs.

Adenocarcinoma of the fourth portion of duodenum presenting as intussusception: an unusual manifestation of rare pathology

Primary adenocarcinoma of the fourth portion of the duodenum (D-IV) is reported infrequently than other parts of the duodenum. Its diagnosis is often late because of non-specific symptoms and signs. We encountered a 48-year-old male patient who was diagnosed as duodeno-duodenal intussusception, underwent segmental duodenal resection with duodenojejunal anastomosis and confirmed as adenocarcinoma of D-IV. He received adjuvant chemotherapy and is doing well at 1 year of follow-up. This report describes about the rare case of isolated adenocarcinoma of the D-IV presented as intussusception which is never reported before and successfully treated by segmental resection of the duodenum and jejunum.

Unroofing and argon mucosal remnant ablation of neonatal duodenal duplication cyst

Background Duodenal duplication cyst is an uncommon foregut malformation usually diagnosed at birth or during infancy. Differently from elsewhere, sited small bowel duplications cannot be removed with simple bowel resection, because of the proximity of the biliary and pancreatic ducts also possibly with abnormal course. Case presentation We report a duodenal duplication cyst in a newborn female requiring early surgery because of nutritional difficulties. The cyst was located adjoined to the second portion of the duodenum sharing part of its muscle wall with the bowel. It was treated by removal of all the esophytic cyst while the remaining mucosa on the common wall with the duodenum was ablated with argon plasma coagulation, preserving the bowel integrity. Early postoperative period was uneventful, and the child could be fed per os on the second day. Yearly follow-up was maintained until 16 years for the risk of recurrence and cancer change due to the incomplete excision. Clinic and echographic controls had always been stayed free from any sequelae. Conclusions Foregut duplications should be removed totally to prevent complications and the long-term risk of cancer, but a duodenal resection can be a harmful surgery in neonatal age. Duplication cysts that are impossible to remove totally can be treated by unroofing and argon plasma coagulation of mucosal surface remnants, avoiding the risks of major procedures also in newborns.

A Case of Primary Duodenal Liposarcoma

Soft tissue sarcomas are common neoplasms accounting for 1% of all adult malignancies; however, soft tissue sarcomas infrequently arise from the abdominal viscera. Many case reports discuss gastric and esophageal neoplasms. In the group of gastrointestinal liposarcomas, primary duodenal liposarcomas are among the rarest, with only three previous cases reported in the literature. Herein, we discuss a case of primary duodenal liposarcoma. A 59-year-old woman presented with symptoms consistent with anemia raising suspicion for an upper gastrointestinal bleed. Upper endoscopy revealed an ulcerated mass in the first portion of the duodenum. The patient underwent a segmental duodenal resection and distal gastrectomy with Roux-en-Y reconstruction. A diagnosis of dedifferentiated liposarcoma was rendered on the resected specimen. At 16 months’ follow-up, the patient remains without evidence of disease recurrence. We have presented a case of primary duodenal liposarcoma, which is among the rarest locations for gastrointestinal sarcomas with only three previous reports in the literature. Liposarcomas should be included in the differential for submucosal masses of the duodenum.