A case of pancreaticoduodenectomy and partial hepatic resection as repeat cytoreductive surgery for recurrent pseudomyxoma peritonei

Background For recurrent pseudomyxoma peritonei (PMP), repeat cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can provide survival benefits if patients are carefully selected. We describe a case of pancreaticoduodenectomy and partial liver resection (HPD) as the repeat CRS for a recurrent tumor that infiltrated the pancreatic head around the hepatic hilum. This is the first report of HPD for recurrent PMP. Case presentation The patient was a 58-year-old male without comorbidities. In 2001, he was diagnosed with PMP at the time of laparoscopic cholecystectomy. In 2004, CRS, including total peritoneal resection, pyloric gastrectomy, splenectomy, and right hemicolectomy with HIPEC was performed (peritoneal cancer index (PCI) = 28). In 2008, the first repeat CRS with HIPEC was performed (PCI = 14). In 2016, fourth repeat CRS, including partial hepatectomy with HIPEC for recurrence of the round ligament of the liver, was performed. In 2017, a tumor of 5 cm in size was observed from the hepatic hilum to the pancreatic head, which infiltrated the main pancreatic duct. Other tumors 2 cm in size were observed (PCI = 7). We performed the fifth repeat CRS, including HPD. The adhesions of the small intestine from around the liver to the lower abdomen were detached for the reconstruction of pancreatojejunostomy and cholangiojejunostomy. The uncinate approach was applied for the pancreatic head resection because it was difficult to identify the cranial part of the pancreas due to adhesions in the hepatoduodenal ligament and the omental bursa. We approached to the origin of the extrahepatic Glissonean pedicle by resecting a part of the liver around the hepatic hilum using transhepatic hilar approach. A complete cytoreduction was achieved. The postoperative pathological diagnosis was a recurrence of PMP, which is equivalent to peritoneal mucinous carcinomatosis. He was discharged on the 22nd postoperative day without major postoperative complications. The patient survived without recurrence four years after HPD. Conclusions Even for recurrence around the hepatic hilum and the pancreatic head, repeat CRS can be safely performed by applying the techniques of hepatobiliary pancreatic surgery.

Lack of Oncological Benefit from Bursectomy in Radical Gastrectomy: A Systematic Review

<b><i>Background:</i></b> Resection of the omental bursa has been suggested to reduce peritoneal recurrence and facilitate a complete oncological resection during a gastrectomy. The addition of this procedure increases technical complexity and prolongs the procedure. Published data regarding the oncological benefit of this procedure are conflicting. We hypothesized that a bursectomy during a radical gastrectomy does not improve overall survival. <b><i>Methods:</i></b> In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, a comprehensive literature search of 3 electronic databases (PubMed, Scopus, and Embase) was conducted to identify the clinical studies that compared bursectomy with no-bursectomy in radical gastrectomy for gastric adenocarcinoma. Qualitative and quantitative data synthesis was performed using RevMan software. A random-/fixed-effect modeling was used depending upon the heterogeneity. Bias and quality assessment tools were applied. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019116556). <b><i>Results:</i></b> Of 8 studies assessing the role of bursectomy in gastric adenocarcinoma, 6 (75%) were included – of which 2 (33%) are randomized controlled trials. Of 2,904 patients, 1,273 (%) underwent a bursectomy. There was no statistically significant difference in either overall survival (hazard ratio [HR] = 0.89, 95% CI 0.75–1.06, <i>I</i>² = 14%) or disease recurrence (HR = 1.01, 95% CI 0.84–1.20, <i>I</i>² = 22%) in the bursectomy group compared to the no-bursectomy group. <b><i>Conclusion:</i></b> There is no additional oncological benefit of adding bursectomy to radical gastrectomy in all patients with gastric adenocarcinoma.

CLINICAL OBSERVATION OF UNTREATED SYSTEMIC LUPUS ERYTHEMATOSUS WITH INFECTIOUS COMPLICATIONS AND FATAL OUTCOME

Among rheumatic diseases, a special place is occupied by systemic lupus erythematosus (SLE), this is due to its variety of clinical nonspecific manifestations, which leads to diagnostic difficulties in the early stages.This article presents a clinical case of severe SLE, previously not diagnosed and untreated, with the rapid progression of multiple organ failure (damage to the lungs, cardiovascular system, kidneys), which led to death. Previously, the patient was treated in the oncology and surgical departments with an abscess of the omental bursa and steatopancreonecrosis, later she was hospitalized in the hematology department with three-growth pancytopenia and hemolytic anemia, and from there transferred to the rheumatology department. This clinical situation demonstrates the importance of timely diagnosis, diagnosis and treatment of SLE.

NECROTIZING PANCREATITIS: THE WAYS OF IMPROVEMENT OF SURGICAL TREATMENT

Background. In connection with a steady increase of patients with destructive forms of acute pancreatitis, the proportion of which takes from 10-15 to 20-30%, despite of the wide range of treatments for non-biliary necrotizing pancreatitis, the rate of mortality reaches 80-90% in case of infected forms and needs further improvement of therapies. Objective. The purpose of this study is to improve the results of treatment of patients with nonbiliary necrotizing pancreatitis, by optimizing surgical tactics. Methods. The study examined the cases of 120 patients, whose age ranged from 22 to 83 years, including patients under the age of 50 years old who accounted for 60.0%. There were 80 males (66.7%) and 40 females (33.3%). Disease duration up to 24 hours was found in 36 (30.0%) patients, from 25 to 72 hours - in 25 (20.8%) individuals, more than 72 hours - in 49 (49.2%) patients. Results. The research claims in non-necrotizing pancreatitis, left-sided retroperitoneal phlegmon often develops in 64.2% (mortality rate 26.0%) of patients, right-sided in 24.2% (mortality rate 6.8%) of patients, and bilateral - in 11, 6% (mortality rate 64.2%) individuals. Moreover, the highest mortality was observed with a combination of retroperitoneal phlegmon cellulose and abscess of the pancreas and/or omental bursa - 39.1%. Conclusions. The use of various surgical interventions depending on the involvement in the pathological process of various sections of the abdominal cavity/ retroperitoneal space, which made it possible to reduce mortality and hospitalization time of patients in the hospital by 1.5-2 times is proposed.

Rare Forms of Intestinal Obstruction in Children

The article analyzes two rare cases of acquired intestinal obstruction in children. In the first child at the age of 2 years, who suffered a retrosternal total coloesophagoplasty for extended post-burn chemical esophageal stenosis, early postoperative adhesive intestinal obstruction appeared on the 8th day of the postoperative period, which was eliminated laparoscopically. The next day, against the background of drug stimulation of the intestine, a small intestinal invagination developed, diagnosed with ultrasound examination. Relaparotomy and disinvagination were performed.The second patient, the 15 years old girl, who had suffered from closed abdominal injury and a pancreatic injury, manifested the signs of high partial intestinal obstruction a day after the trauma occurred. Initially, its cause was considered to be hematoma of the omental bursa. Fibrogastroduodenoscopy (FGDS) and X-ray diagnostics did not reveal the cause of intestinal obstruction, but after FGDS procedure the patient’s condition improved within 3–4 days, and then the clinical signs of small bowel obstructive adhesion confirmed by X-ray and laparoscopy. With laparoscopy in the middle section of the small intestine, a hyperinflate “whitish” section about 12 cm long, dense in palpation, was identified, which was the cause of obstruction. Through minilaparotomic umbilical access from the abdominal cavity, a loop of the jejunum with a foreign body inside was exteriorized. With transverse enterotomy trihobezoar 10×4×4 cm was removed from the lumen, which moved from the stomach and led to obstruction of small intestine. The outcome of the treatment was good in both cases.

Comparative analysis of the data on the structure of omental bursa

This essay is about the differences in the description of the upper story of the peritoneal cavity, the omental bursa and omental (epiploic) foramen, which connects the omental bursa (lesser sac) with the rest of the peritoneal cavity (greater sac). The difference in the description of the omental bursa causes misunderstanding during the study of the topic «The stories of the peritoneal cavity». The misunderstanding is especially well expressed when we teach the foreign students because there is a great difference in the description of the omental bursa in Russian and English literature. That is why we decided to analyze the data of the omental bursa in different literal sources. We analyzed 11 textbooks, 5 of the mare Russian and 6 of the mare English, most useful for the students during the preparing the material for Anatomy classes. The results are given in tables.