Clear Cell Carcinoma of the Pancreas Infiltrating Duodenum: A Case Report of a Multiface Aspect of an Intriguing Entity

Background: Although Clear-cell carcinoma has been found in various organs as a variant of ductal carcinoma of the pancreas, it still hasn’t been well recognized. According to the WHO classification, primary Clear-cell carcinoma of the pancreas is rare, and it is classified as a “miscellaneous” carcinoma. To date it has been poorly characterized and only few cases have been reported in the literature [1]. Case presentation: We report here an unusual case of Clear-cell carcinoma in a 59-year-old man involving the head of the pancreas and the second part of the duodenum initially misconceived as pyloric gland adenoma, a rare duodenal entity. Nevertheless, duodenal sub stenosis was suspected of malignancy, so further investigations were made. Subsequent abdominal computed tomography (CT) detected not only a duodenal vegetation but also an alteration of the duodenal-pancreatic interface with thickening of the duodenal wall and a common bile duct dilatation. The malignant clinical aspect and behavior of the lesion, associated to the impossibility of further investigations due to the duodenal sub stenosis, led to an exploratory laparotomy.The laparotomy revealed a retracting area straddling the duodenum and the pancreatic head. A duodenum pancreatectomy of the head of the pancreas with extended lymphadenectomy was performed and the histological evaluation showed a ductal Clear-cell adenocarcinoma of the pancreas infiltrating the duodenum. The postoperative course was characterized by a pancreatic fistula grade B. At 6 months from the surgery, the patient hasn’t had recurrence.Conclusion: Because it is a rare tumor with very few cases reported previously, the incidence and prognosis are not well known for this neoplasm. The report of our case would aid in the identification of this rare neoplasm. Further studies and more case reports are needed to clarify the diagnosis and prognostic significance of the clear cell differentiation of these tumors.

COVID-19 induced aorto duodenal fistula following evar in the so called “negative” patient

Objectives Since October 2019, SARS-CoV-2 pandemic represents a challenge for the international healthcare system and for the treatment and survival of patients. We normally focus on symptomatic patients, and symptoms can range from the respiratory to the gastrointestinal system. In addition, we consider patients without fever and respiratory symptoms, with both a negative RT nasopharyngeal swab and lung CT, as a “Covid-19 negative patient.” In this article, we present a so called Covid-19 “negative” patient, with an unsuspected vascular clinical onset of the viral infection. Methods An 80 y.o. man, who previously underwent endovascular aortic repair for an infrarenal abdominal aortic aneurysm, presented to our department with an atypical presentation of an aorto-enteric fistula during the pandemic. While in hospital, weekly nasopharyngeal swab tests were always negative for SARS-CoV-2. However, the absence of aortic endograft complications, the gross anatomy of duodenal ischemic injury, and the recent history of the patient who lived the last months in Bergamo, the Italian city with the highest number of COVID-19 deaths, lead the senior Author to suspect an occult SARS-CoV-2 infection. The patient underwent to resection of the fourth portion of the duodenum and the first jejunal loop, with subsequent duodenum–jejunal latero-lateral anastomosis and the direct suture of the aortic wall. The intestinal specimen was investigated as suspected SARS-CoV-2 bowel infection by the means of immune-histochemistry (IHC). An ileum sample obtained in the pre-COVID-19 era was used as a control tissue. Results The histological analysis of the bowel revealed sustained wall ischemia and liponecrosis of the duodenal wall, with intramural blood vessels thrombosis. Blood vessel endotheliitis and neo-angiogenesis were also observed. Finally, the IHC was strongly positive for SARS-CoV-2 RNA and for HLA-G presence, with a particular concentration both in blood vessels and in the intestinal villi. The control tissue sample was not positive for both SARS-CoV-2 and HLA-G. Conclusions Coronavirus pandemic continues to be an international challenge and more studies and trials must be done to learn its pathogenesis and its complications. As for thromboembolic events caused by SARS-COV-2, vascular surgeons are involved in treatment and prevention of the complications of this syndrome and must be ready with general surgeons to investigate atypical and particular cases such as the one discussed in this article.

Novel 15-mm-long lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections located ≥10 mm from the luminal wall

Background Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away. Methods This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence. Results 35 patients (median age 57 years; interquartile range [IQR] 47–64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64–117) maximal diameter and located 11.8 mm (IQR 10–12.3; range 10–14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58–236). Three complications occurred (9 %; one mild, two moderate). Conclusions The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10–14 mm from the luminal wall.

Intrahepatic Dynamic Contrast‐Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein‐Losing Enteropathy in Congenital Heart Disease

Background Protein‐losing enteropathy (PLE) is a significant cause of morbidity and mortality in congenital heart disease patients with single ventricle physiology. Intrahepatic dynamic contrast‐enhanced magnetic resonance lymphangiography (IH‐DCMRL) is a novel diagnostic technique that may be useful in characterizing pathologic abdominal lymphatic flow in the congenital heart disease population and in diagnosing PLE. The objective of this study was to characterize differences in IH‐DCMRL findings in patients with single ventricle congenital heart disease with and without PLE. Methods and Results This was a single‐center retrospective study of IH‐DCMRL findings and clinical data in 41 consecutive patients, 20 with PLE and 21 without PLE, with single ventricle physiology referred for lymphatic evaluation. There were 3 distinct duodenal imaging patterns by IH‐DCMRL: (1) enhancement of the duodenal wall with leakage into the lumen, (2) enhancement of the duodenal wall without leakage into the lumen, and (3) no duodenal involvement. Patients with PLE were more likely to have duodenal involvement on IH‐DCMRL than patients without PLE ( P <0.001). Conclusions IH‐DCMRL findings of lymphatic enhancement of the duodenal wall and leakage of lymph into the duodenal lumen are associated with PLE. IH‐DCMRL is a useful new modality for characterizing pathologic abdominal lymphatic flow in PLE and might be useful as a risk‐assessment tool for PLE in at‐risk patients.

EP.TH.691Necrotic Liver Abscess secondary to Duodenal Perforation caused by ingestion of a Fish Bone – A Case Report

Introduction Ingestion of foreign bodies are not uncommon, however enterohepatic migration of fish bones causing liver abscesses remains a rare phenomenon. Case Report We present the case of a 58-year-old female admitted with 11 days history of fever, rigors, shortness of breath and malaise associated with vomiting and diarrhoea. Her COVID-19 rapid antigen test was negative. She was tender in the left lower quadrant of her abdomen and inflammatory markers were markedly high so initial differential diagnosis included colitis and diverticulitis. Contrast Computed Tomography of the abdomen and pelvis showed an 8.1cm irregular hepatic lesion initially thought to be a multi-loculated abscess, malignancy or complex cyst. She was started on broad-spectrum antibiotics, escalated to Intensive Care Unit (ICU) and discussed at the hepato-biliary multi-disciplinary team (MDT) where magnetic resonance images demonstrated a perforated duodenum from a 2.5cm fish bone penetrating from the duodenal wall into the liver parenchyma causing a necrotic abscess. She underwent percutaneous drainage of the hepatic abscess. Endoscopic retrieval was then attempted; however, the fish bone was not visualised. Definitive management followed with laparoscopic removal of the fish bone and primary duodenal repair. Discussion Identification of the cause of the abscess during MDT discussion enabled prompt source control which was key in managing intra-abdominal sepsis – radiological drainage in the first instance prevented secondary peritonitis from a potentially ruptured abscess and enabled the patient to be de-escalated from ICU. Previous literature suggests endoscopic retrieval however, laparoscopic surgery remains safer for managing complications following removal of sharp foreign bodies.

Resección endoscópica de hamartoma gigante de glándulas de Brunner. Reporte de un caso

Brunner's gland hamartoma or hyperplasia is a rare benign neoplasm of the small intestine, usually small, that is discovered incidentally on an upper digestive endoscopy or imaging tests. When it reaches a large size, it can cause digestive bleeding or intestinal obstruction. The pathogenesis is unknown. The endoscopic presentation can be nodular, polypoid or a diffuse glandular proliferation with thickening of the duodenal wall, and may be mistaken for a malignant neoplasm. Endoscopic resections of large Brunner's gland hamartomas in the duodenum is little reported in literature, due to its low incidence and diagnostic difficulty. The surgical approach is associated to greater morbidity compared to an endoscopic approach. The case of a 62-year-old patient is reported, who presented melena and symptomatic anemia, secondary to a giant polyp in the duodenal bulb. The polyp was successfully resected endoscopically without complications, which made it possible to avoid a more extensive surgical procedure. Histopathological examination of the whole specimen showed a Brunner's gland hamartoma. Conclusion: Brunner's gland hyperplasia or hamartoma is a benign neoplasm that rarely produces symptoms. Large lesions can become symptomatic and a high clinical-endoscopic suspicion and an evaluation of the extension are necessary before applying any therapeutic procedure, in order to avoid complex surgeries and favor a complete and safe endoscopic resection.

ESD-aid Surgery as a New Treatment Strategy for Duodenal Adenoma

BackgroundThe treatment for nonampullary duodenal adenoma remains to have no consensus and established methods. Although endoscopic treatment is minimally invasive, it was reported to cause delayed perforation in more than 20% of cases. MethodsFor adenomas in the duodenum, we have performed ESD-aid surgery, which is a procedure to prophylactically suture the seromuscular structure of the duodenum after ESD. In this procedure, we did not perform Kocher mobilization prior to ESD to facilitate endoscopic resection and full-thickness resection to prevent spread of the tumor and infection to the abdominal cavity. The duodenal wall was reinforced in planes using a suture clip. ResultsOf the 13 cases of duodenal adenoma that underwent ESD-aid surgery at our hospital between April 2018 and December 2020, 1 developed postoperative bleeding, but there was no late perforation. ConclusionsFor duodenal adenomas, ESD-aid surgery was considered a safe and minimally invasive treatment.Trial registrationThis research was approved by the institutional review board of Nagoya City University Hospital, Approval Number: 60-19-0021, Approval Date: 4 June 2019.